literature review of family planning research in ethiopia

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Research Article

Family Planning Knowledge, Attitude and Practice among Married Couples in Jimma Zone, Ethiopia

Contributed equally to this work with: Tizta Tilahun, Gily Coene, Stanley Luchters, Wondwosen Kassahun, Els Leye, Marleen Temmerman, Olivier Degomme

* E-mail: [email protected]

Affiliation College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia

Affiliation Rhea, Research Center on Gender and Diversity, Brussels University, Bussels, Belgium

Affiliations International Centre for Reproductive Health, Department of Obstetrics and Gynecology, Ghent University, Ghent, Belgium, Burnet Institute, Monash University, Victoria, Australia

Affiliation International Centre for Reproductive Health, Department of Obstetrics and Gynecology, Ghent University, Ghent, Belgium

Tizta Tilahun,
Gily Coene,
Stanley Luchters,
Wondwosen Kassahun,
Els Leye,
Marleen Temmerman,
Olivier Degomme

Published: April 23, 2013
https://doi.org/10.1371/journal.pone.0061335
Reader Comments

Understanding why people do not use family planning is critical to address unmet needs and to increase contraceptive use. According to the Ethiopian Demographic and Health Survey 2011, most women and men had knowledge on some family planning methods but only about 29% of married women were using contraceptives. 20% women had an unmet need for family planning. We examined knowledge, attitudes and contraceptive practice as well as factors related to contraceptive use in Jimma zone, Ethiopia.

Data were collected from March to May 2010 among 854 married couples using a multi-stage sampling design. Quantitative data based on semi-structured questionnaires was triangulated with qualitative data collected during focus group discussions. We compared proportions and performed logistic regression analysis.

The concept of family planning was well known in the studied population. Sex-stratified analysis showed pills and injectables were commonly known by both sexes, while long-term contraceptive methods were better known by women, and traditional methods as well as emergency contraception by men. Formal education was the most important factor associated with better knowledge about contraceptive methods (aOR = 2.07, p<0.001), in particular among women (aOR women = 2.77 vs. aOR men = 1.49; p<0.001). In general only 4 out of 811 men ever used contraception, while 64% and 43% females ever used and were currently using contraception respectively.

The high knowledge on contraceptives did not match with the high contraceptive practice in the study area. The study demonstrates that mere physical access (proximity to clinics for family planning) and awareness of contraceptives are not sufficient to ensure that contraceptive needs are met. Thus, projects aiming at increasing contraceptive use should contemplate and establish better counseling about contraceptive side effects and method switch. Furthermore in all family planning activities both wives' and husbands' participation should be considered.

Citation: Tilahun T, Coene G, Luchters S, Kassahun W, Leye E, Temmerman M, et al. (2013) Family Planning Knowledge, Attitude and Practice among Married Couples in Jimma Zone, Ethiopia. PLoS ONE 8(4): e61335. https://doi.org/10.1371/journal.pone.0061335

Editor: Hamid Reza Baradaran, Tehran University of Medical Sciences, Iran (Islamic Republic of)

Received: November 28, 2012; Accepted: March 7, 2013; Published: April 23, 2013

Copyright: © 2013 Tilahun et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: We also thank Belgium Institutional University Cooperation programme with Jimma University, Ethiopia for funding the research. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

The lifetime risk of maternal mortality of women in sub-Saharan Africa is 1 in 39 live births, which is the highest when compared to other world regions. The World Health Organization (WHO) estimated in 2012 that 287,000 maternal deaths occurred in 2010; sub-Sahara Africa (56%) and Southern Asia (29%) accounted for the global burden of maternal deaths [1] . One of the targets of the Ethiopian Ministry of Health, with respect to improving maternal and child health, is to increase the contraceptive prevalence rate (CPR) from 32% to 66% by 2015. In order to achieve this target, the Ministry has given priority to the provision of family planning services in the community [2] .

With 87 million people, Ethiopia is the second most populous nation in sub-Saharan Africa, with a continuing fast growing population of 2.7% per year [3] . The maternal mortality ratio (MMR) is 676 per 100 000 women aged 15 to 49, with an estimated 32% of all maternal deaths attributed to unsafe abortions [4] . A study conducted in Northwest Ethiopia in 2005 indicated that prevalence rates of spontaneous and induced abortions were estimated at 14.3% and 4.8% of all pregnancies respectively [5] .

Despite the recent increase in contraceptive use, sub-Saharan Africa is still characterized by high levels of fertility and a considerable unmet need for contraception [6] . The total fertility rate in Ethiopia is 4.8 births per woman and is considerably higher in the rural then the urban areas. Observed fertility rates among women are 33% higher than the wanted fertility rates. In absolute numbers, this means 0.6 additional children in urban areas and 1.5 in rural areas. This is particularly the case in Oromiya region where the total fertility rate is as high as 5.6 children per woman and 30% of the currently married women have an unmet need for contraception which represents the highest figure of all regions in Ethiopia [4] . In the five years preceding the Ethiopia demographic Health Survey (EDHS) in 2011 it is estimated that, three births of every four (72%) were wanted at that time, 20% were wanted but not at the time of pregnancy, and 9% were unwanted [4] . A better use of family planning could reduce many of these mistimed and unplanned pregnancies, while at the same time it could reduce the number of unsafe abortions as well as the mortality related with child birth [7] .

On the other hand, couples have a right to choose and decide upon the number of children they desire. This means that both partners have the right to be involved in fertility matters and as such husbands play a crucial role in fertility decision-making in most of the world [8] . Clearly, male-involvement in family planning has positively affected contraceptive use and has caused an overall decline in fertility in the developing world. Men's fertility preferences and attitudes towards family planning seem to influence their wives attitudes towards the use of modern contraceptives [9] . Therefore, programs that attempt to promote reproductive health through increasing the use of modern contraceptives need to target men specifically at all levels of the program. Hence, men should be actively involved at the ‘knowledge’ level (the concept of family planning), the ‘supportive’ level (being supportive for other to use contraception) and the ‘acceptor’ level (as contraceptive user). Their decision-making role should be taken into account in order to promote contraceptive use [10] . Similar research indicates that women's feelings about their partners and about involving men in contraceptive and reproductive decisions must always be taken into account [9] . Previous studies indicated that acceptance of children as God's will, attitudes towards preventing pregnancy, knowledge on different method choice and the understanding of the side effects of different methods are among the factors related to contraceptive use [11] , [12] . Moreover, studies on perception of spousal approval and opposition from husbands are positively associated with low contraceptive use [13] .

Given the above factors associated with contraceptive use, the primary objective of this study was to examine the contraceptive prevalence rate among married couples and to study the factors that influence contraceptive use. A secondary objective was to determine knowledge on contraceptives (method-specific; including barrier, hormonal, permanent and dual protection methods), and attitudes towards family planning. Finally, fertility preference among married couples was assessed to see the variation between men and women.

Materials and Methods

This analysis forms part of a baseline assessment for a broader study aimed at determining the effect of a family planning education intervention on the knowledge, attitude and practice of married couples regarding family planning as well as male involvement (will be disseminated separately). The study is conducted in Jimma Zone, one of 14 administrative zones of Oromyia region located in the Southwest of Ethiopia. Its capital, Jimma, is found 352 km to the south west of the national capital, Addis Ababa. Jimma Zone is an area of 15,568.58 Km 2 with 17 woredas (districts) and one special zone. According to the 2007 national census, the total population is 2,486,155, of whom 1,250,527 are men and 1,235,628 women [14] .The rural part counts for 89.5% of the total population size of the zone in which the dominant ethnic group is the Oromo. The study area is thus a typical rural setting.

The study population consisted of couples (women and their husbands) who were legally married, lived for more than six months in the study area and of which the wives were 15–49 years (the reproductive age group) but not pregnant at the time of the survey. Husbands within a polygamous marriage (who had more than one wife) were excluded from the analysis to decrease redundancy of information. A multi-stage sampling design was used with districts ( woredas ) as primary sampling units (PSU), and sub-districts ( kebeles ) as secondary sampling units (SSU). The study covered three woredas i.e. Seka, Manna and Gomma, in which six kebeles were randomly selected: Goyoo qechema, Koffie, Gobiemuleta, Haro, Gembie and Bulbulo. In each selected kebele , a complete census of married couples was prepared to use as a sampling frame. Married couples were then randomly sampled from each locality, based on a computer generated random number list until the required size was achieved.

The sample size was computed using Minitab version 14 statistical software in the context of the broader intervention study. Adding 10 percent for non- responses resulted in a final sample size of 427 couples per group or 854 for the entire sample to be drawn equally from each sub-districts.

This study consisted of two parts, including quantitative and qualitative data collection techniques. Data for the quantitative study were collected using semi-structured questionnaires. Separate questionnaires were administered for male and female respondents but with similar contents including socio-demographic characteristics (age, sex, ethnicity, occupational status, income, age at first marriage), reproductive characteristics (number of children, sex preference of couples), as well as question modules on knowledge, attitudes and practice regarding contraceptive use (types of contraception, use of contraception, user perspective, attitudes of a husband and wife towards contraceptives, husband-wife communication on family planning, ever use of contraceptives, current use of contraceptives and reasons for not using contraceptives).

The questionnaire includes not only types of contraceptive as knowledge part but also how to use, where to get family planning service, side effects of contraception and other points too. The survey instruments were developed from a validated questionnaire and were considered valid and reliable through the favorable comments of experts for obtaining information on couples about knowledge, attitude and contraceptive practice [8] , [9] , [15] , [16] . Pilot testing of 5% of the sample revealed that respondents were able to understand and answer questions. Six male and six female data collectors participated in the study and were supervised by three field coordinators. Data collectors were recruited from the local community. We paired the data collectors by sex: men to husbands and female to wives because of the sensitivity of the issue. Interview conducted in private location, each couple at a time but separately keeping the interviewee privacy. Interview conducted if both spouses willing to participate.

For the qualitative data, focus group discussions, using a semi-structured topic guide were employed. Focus group discussions were done to probe to understand the phenomena of couples contraceptive practices within the society. The semi-structured topic guide covered the socio-cultural factors related with contraception and husband's responsibility towards contraception. Four groups consisted of married women and four groups consisted of married men, making a total of eight focus group discussions. Each focus group discussion consisted of 8 to 12 participants. Participants were selected purposively based on who can give the most and best information about coupes contraceptive practice. The participants were married individuals. The group discussions were moderated by university graduates who speak the local language. Similar to the quantitative part, focus group discussions were done female to female and male to male moderators. For the qualitative data participants were first given number a code and their characteristics registered (age and sex). At each time the participant wanted to give an idea first he/she has to call the number. Notes on points of discussion was taken in addition to tape recording.

Data analysis

The data set for this analysis contained data from 854 husbands and their wives. For the quantitative data analysis, STATA® 10 for Windows® was employed. Analyses were done at the level of the individual independently from the spouses. Simple descriptive analysis was done to explore levels of awareness, knowledge (on different types of contraceptive and knowledge level), attitude and practice among respondents. Bivariate analysis was used to investigate the effect of demographic and socioeconomic variables on fertility preferences and contraceptive practice. Finally, multivariate logistic regression was used to identify predictors of these outcome variables. Statistical significance was considered at p-values less than 0.05.

Qualitative data from focus group discussions were recorded as sound files using tape and subsequently transcribed to text files. Transcripts of the recorded discussions were coded and analysed using thematic areas manually and participants' identifying details were removed. No computer software was used for qualitative data analysis.To check the internal consistency and reliability, data from the quantitative part was used to triangulate with the qualitative results

Ethical considerations

Ethical clearance of the study was obtained from the research and ethics committee of the College of Public Health and Medical Sciences, Jimma University, Southwest Ethiopia and Ghent University's Ethical Committee in Belgium. Written consent was obtained from each man and woman participating in the study after the data collectors explained about the purpose of the study using a predefined information sheet. Written informed consent was taken from spouses on the behalf of those wives for who were in the age less than 18 years. No compensation was rendered as direct incentive to the participants. The ethics committees approved this consent procedure.

Socio Demographic Characteristics

A total of 811 out of 854 sampled couples responded, equating to a response rate of 94.9%. All women were between 15 and 49 years (as per inclusion criteria), with a median age of 30 (IQR = [25;35]). Median age among males was 36 (IQR = [30;45]) (see Table 1 ).

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https://doi.org/10.1371/journal.pone.0061335.t001

Almost two-thirds of the women (n = 532, 66%) had not received education, but 204 (25%) had completed primary education; among men, 184 (23%) had not received education while 437 (54%) had completed primary schooling.

Oromos were the principal ethnic group accounting for 1,417 (87%) individuals; 97 (6%) others were Dawro, 28 (2%) Keffa, 25 (2%) Yem, 23 (1%) Amhara, and 32 (2%) from other ethnic groups. The majority of the respondents, 743 (92%) women and 737 (91%) men, were Muslim; second most prevalent religion was Orthodox Christianity with 55 (7%) women and 53 (7%) men. Education levels were different across these two most prevalent religions: 66 out of 1480 (4%) Muslims had completed secondary education in comparison to 16 of the 108 (15%) Orthodox Christians (χ 2 (1, N = 1588) = 19.98, p<0.001). Similarly, Amhara, Yem and Tigrie, of which approximately 25% are Orthodox Christians, showed higher levels of literacy than the other population groups (χ 2 (1, N = 1622) = 10.46, p = 0.001).

Agriculture was the main occupation of the interviewees with 732 (90%) men and 668 (82%) women; 71 (9%) of the women reported being housewives. The median income of couples was 225 Birr (IQR = [150;370]), which is approximately 9.3 Euro, per month, according to information obtained from the wives. Daily laborers had a median income of 150 Birr per month, government employees 700 Birr.

The median household size was 5 (IQR = [4;6]), with a median of 3 children, and 422 (52%) households comprised of five to seven members. Literate respondents had smaller household sizes than the illiterate (χ 2 (11, N = 811) = 28.23, p = 0.003), as well as less children (χ 2 (10, N = 811) = 30.48, p<0.001). The median age at first marriage for men aged 20–59 was 21 (IQR = [20;25]) and 16 (IQR = [15;18) for women aged 20–49. There were 40 (5%) males and 518 (65%) females who married before age 18. The median duration of the couple's marriage was 11 years (IQR = [6;19]). Among the husbands, 209 (26%) stated having been married already prior to the current union.

One-third of the female respondents (n = 296, 36%) reported having ever lost at least one child; 209 (70.6%) reported ever having lost at least one boy, 181 (61%) at least one girl.

More than 98% of the study participants had access to health facilities providing family planning services in their surrounding (at least health post i.e Primary level health care in Ethiopia (can serve 3,000–5,000 individuals).

Fertility preferences

A majority wanted to have more children: 494 (72%) among the men, 439 (64%) among the women. The median desired number of children before using family planning among both women and men was 4 (IQR = [3;5]). Of the 233 women who had reached or exceeded their desired number of children, 90 (39%) still reported a need for more children; on the other hand, among the men having reached or exceeded that number, 131 out of 252 (52%) wanted more children.

Overall, 413 (44%) respondents of the 933 desiring more children expressed a sex preference for the next child. Among men, 172 (35%) wanted a boy versus 47 (10%) a girl; among women these numbers were respectively 120 (27%) and 74 (17%). Sex preference varied depending on the number of boys and girls already living in the family (see Table 2 ). Respondents with no boys had a distinct desire to have a boy as the next child. This preference disappeared among women once they had at least one boy and among men once they had two boys. A similar preference for a girl is noticed for respondents that did not have girls yet, although the extent of this preference is more limited. On average, both men and women had a preference for a boy if they had at least one girl.

https://doi.org/10.1371/journal.pone.0061335.t002

Knowledge about Family Planning

The concept of family planning was well known to respondents: 760 (94%) women and 795 (98%) men responded ever having heard of it. The median number of methods of contraception that were known among men was 5 (IQR = [2;8]) which was the same among women 5 (IQR = [3;6]); the mean was 5.4 for both sexes (95%CI men = [5.2;5.7] and 95%CI women = [5.2;5.5]). As such, there was no statistical difference between the sexes (p = 0.6585). Different levels of knowledge were found across the kebeles : only 3 of the 265 (1%) respondents in Haro knew more than 5 methods of contraception compared to values ranging from 34% to 60% for the other kebeles . No relationship was found between knowledge level and age, religion or ethnic affiliation. Formal education on the other hand, was associated to a higher knowledgeability about contraceptive methods (aOR = 2.07, p<0.001), in particular among women (aOR women = 2.77 vs. aOR men = 1.49; p<0.01).

Method-specific knowledge levels varied from 12% for vaginal contraceptives (diaphragm, foam, jelly) to 94% for injectable contraceptives. Differences were found between men and women ( Table 3 ). Only short-term hormonal methods like the contraceptive pill and injectable contraceptives were consistently well known by both sexes. Least known were the permanent methods, traditional methods and emergency contraception. Major differences between women and men were noted for the long-term hormonal methods (χ 2 (1, N = 1622) = 217.96, p<0.001) and emergency contraception (χ 2 (1, N = 1622) = 140.12, p<0.001). A total of 1064 (68%) respondents knew how to use contraceptives, with more women (77%) being knowledgeable about it than men (58%) (χ 2 (1, N = 1622) = 67.42, p<0.001). Similarly, knowledge on contraceptive use decreased with increasing age even when correcting for sex (aOR per additional year of life = 0.98; p = 0.003).

https://doi.org/10.1371/journal.pone.0061335.t003

Attitudes towards Family Planning

Of the 1622 respondents, 91% (1479) were in favour of family planning; logistic regression showed that factors associated with a more positive attitude towards family planning were: being a man (aOR = 1.67; p = 0.021), young age (aOR per additional year of life = 0.97; p<0.001) and being literate (aOR = 1.89; p = 0.002). Male respondents were asked specifically whether they would support their wives to use family planning. Of the 811 male respondents, 751 (93%) answered positively and 22 (3%) negatively. This finding was corroborated during the focus group discussions with married men.

“Couples should limit their number of kids for the seek of child's health and for the household economy.” (Male, 18 years)

Contraceptive Practice

We did not consider husbands' number of children at first contraceptive use as only 4 (0.2%) males reported having ever used contraceptives. Condom use was thus very low. Among women, 517 (64%) ever used a method of contraception; 350 (43%) were using contraception at the time of the survey. This difference in contraceptive use between men and women was corroborated by the focus group discussions as these showed that both married women and men mostly considered contraceptive use as a woman's task:

“What will I do in a family planning clinic, contraception is women's business, I will just give my wife the necessary financial support she needs” (Male, 45 years)

Two hundred sixty five (51%) wives had one to two children at their first contraceptive use. The median number of children a woman had when starting contraception was 2 (IQR = [2-2]) which corresponds to 2 children less than what they considered the ideal number of children.

The most commonly used methods when starting contraception were injectable (316 out of 515, 39%) and oral (174 out of 515, 21%) hormonal contraceptives. The prevalence of these hormonal contraception methods was much related to the age of the woman. Injectable methods were most common among younger women (aOR per additional year of life = 0.94; p<0.001), while oral contraceptives were more frequently used by older women (aOR per additional year of life = 1.06; p<0.001). Of the 350 women who were using contraceptives at the time of the survey, 283(81%) were using injectables and 33 (9%) oral contraceptives.

Multivariate analysis showed that higher current use of contraception among women was associated with being literate (aOR = 1.58; p = 0.005), the number of children (aOR per additional child = 1.11; p = 0.027) and being highly supportive of family planning (aOR = 4.01; p<0.001). Household income didn't show an association with current contraceptive use (p = 0.593). The same factors were also determinants for contraceptives having ever used.

Reasons given by males for not using contraception included being recently married 235 (29%) and lack of knowledge of the different types of methods 235 (30%). The reason for not using contraception given by both male and females was the desire to have children (419 (51.8%) men and 203 (44%) women). Among women fear of side effects was reported by 106 (23%) as the reason for not using contraception (see Figure 1 ). Likewise, the qualitative findings also indicate fear of contraceptives' side effects as a barrier to use contraception by women:

https://doi.org/10.1371/journal.pone.0061335.g001

“Women don't use contraceptive because they don't want to get pain by the side effect of pills and injectable” (Female, 25 years)

Additional results from focus group discussions indicate that males are at least partly responsible for women not using contraceptives:

“sometimes husbands oppose wife use of contraceptive because they think she does not want to give birth and instead she has an intention to go for another man” (Female, 33 years)

Among women, 183 (36%) of current contraceptive users reported ever having switched between methods, with 175 (96%) of them giving lack of comfort as one of the reason and 99 (54%) fear of side effects. Likewise the qualitative part supports this result.

“I used one type of contraceptive and it result in burning sensation and excessive menses so I changed to other contraception method” (Female, 20 years)

Despite the recent increase in contraceptive use, Ethiopia, Africa's second most populous country, is known to have a low contraceptive prevalence and high total fertility. The objective of the study presented in this paper was to investigate differences among males and females regarding knowledge on contraceptive methods, fertility preference and contraceptive practice among married men and women in Jimma zone, Ethiopia.

The results of this analysis demonstrate that more than 98% of the couples had access to health facilities that deliver family planning. The median household size of five in the study area (Jimma zone) was comparable to the national household size (4.6 persons), especially that of rural areas (4.9 persons) [4] . Literacy was found to be linked to smaller household sizes, which is in line with previous findings [4] , [16] .

Age at first marriage was lower in our study population compared to national figures. For females aged 20–49 years, the median age at first marriage was 16 years, i.e. one year younger than the national median (17.1 years) and a previously published study from Butajira (16.9 years). Among men aged 20–59, a one year difference with the national median was observed (22 years vs 23.1 years). This also corroborates general trends that men marry at older ages than women [4] , [17] .

Similar to EDHS (2011), this study revealed that more men than women have a desire for more children [4] . This suggests that the low use of contraception among men is partly a well-reasoned decision, and not only a consequence of limited knowledge. In this study the mean ideal number of children was 4.2 and 4.6 among men and women respectively. This is in contrast to the national figures that show a difference in the mean ideal number of children between men and women, i.e. 5.9 and 4.9 respectively [4] .

A study conducted in Tigray, Ethiopia reported that the mean desired number of children among men differed significantly as compared to that of women ( Δ = 1.2; 95%CI: [0.87;1.53]) [10] . The inconsistency with our study could partly be explained by a different formulation of questions since we inquired about the ideal number of children before starting contraception, instead of the actual desired number of children. Furthermore, we identified discrepant results with respect to the desired number of children and the desire to have additional children. Considerable numbers of couples that had reached the desired number of children still desired more. Research should be done exploring the causes of this finding.

With regards to sex preference, respondents with no boys had a distinct desire to have a boy as a next child; the same pattern of wanting a girl was observed among couples that didn't have a girl yet. However, the extent of the preference for a girl was more limited. In addition, the preference was stronger among men, a finding that is supported by the results of a study conducted in Ethiopia in which most men (48%) reported that they would like more sons than daughters [18] . This might be due to cultural norms around son preference or, as suggested by others, the interest for more sons could be based on subsistence reasons, such as economic security and maintaining their status within the traditional family structure [19] . From the focus group discussants, a woman (25 years) described that she wants to have five male and three female; because male stay with me but after marriage female follows her husband. Moreover this study reveals nearly 36% women reported ever had child death of which almost 70% boy child. This could be the other possible expatiation for boy sex preference.

The high level of knowledge on at least one form of contraception among the participants of this study (96%) is in line with previously reported national figures (98.4%). In our study, we observed no significant difference between men and women with regards to knowledge: the average number of methods known in both sexes was 5.4 contraceptive types. In contrast, at national level, the average number of contraceptive methods known by men is higher than women (6.3 and 5.4 respectively) [4] . As such, men included in our study were less knowledgeable about different methods compared to the average Ethiopian man.

In the present study, short-term hormonal contraceptive methods like the pill and injectable contraceptives were consistently well-known by both sexes. Permanent methods, traditional methods and emergency contraception on the other hand were the least known contraceptive methods. Compared to the results from the Ethiopian Demographic Health Survey (2011) women and men are more familiar with long term and standard days methods, but in the case of barrier methods (diaphragm/jelly and male condom) and emergency contraception the reverse is true for the study population [4] . In addition our study identified major differences in knowledge of emergency contraception between the two sexes. The limited knowledge of women on emergency contraception suggests that this type of contraception is not part of the standard information package that is given to women in our study area.

Overall, our respondents had a positive attitude towards family planning (91%), but less than 1% of the males and 64% of the women reported having ever used any type of contraception. Other studies have already described similar findings, i.e high awareness but low utilization of contraceptives, making this situation a serious challenge in developing countries [8] , [20] . The EDHS 2011 reported a current contraceptive prevalence rate of 29% for married women, which is lower than our finding (43%) [4] . A reason for this could be that the majority of our respondents have access to health facilities in the study site. With respect to the method-specific contraception, injectables (39%) and oral hormonal contraceptives (21%) were the main methods used. Compared to EDHS 2011, a noteworthy finding in our study is the low use of implants, suggesting that health facilities in our study area are not able to deliver this service.

Among background characteristics of women, literacy, age, the number of children, and being highly supportive of family planning were found to be important indicators of current contraceptive; this is confirmed by different studies [4] , [20] – [22] . Fear of side effects was identified as the reason for not using contraceptives among married women, a finding that has been described already in other studies conducted in Ethiopia and Bangladesh [23] , [24] .

Our qualitative study findings also assured that fear of side effects is one of the most important reasons of not using contraceptives by women. In addition, this study reported that men's reasons for not using contraception were being recently married and the desire for more children. The latter is also one of the most important reasons of not using contraception among women. In general, in the study area the findings indicate a prevailing belief that contraception is only a women's business.

This study has limitations resulting from the design that was used, in the sense that cross-sectional studies do not allow to establish cause-effect relationships. In addition, an important limitation is the exclusion of couples with pregnant women from this baseline study as per the intervention protocol. This clearly affects the contraceptive prevalence rate and could potentially affect some other indicators too. The group of pregnant couples however represented only 7% of all couples from our sampling frame. This leads us to believe that the effect on the figures is probably relatively small. A final potential limitation is reporting bias. It also suffered from social desirability as it is a community based study. In that context, we decided to exclude one kebele (Gobbie Mulata) from the analyses of the ideal number of children as there was evidence of an erroneous comprehension of the question.

Conclusion and Recommendations

The analysis of this study provides information on married men and women on knowledge, attitudes and contraceptive practice in Jimma zone, Ethiopia. Our results demonstrate that good knowledge among males and females was observed, yet differences on knowledge of specific contraception methods exist. The study reveals that mere physical access (proximity to clinics for family planning) and awareness of contraceptives are not sufficient to ensure that contraceptive needs are met. We also noticed the existence of a sex preference for boys both among men and women. Condom use by men is above the national average but it is low compared to most Sub-Saharan African countries. It is evident from this study that high knowledge on contraception is not matched with the high contraceptive use. Among reasons for not using contraception, want to have a child and side effects of contraceptive were given by men and women respectively. Therefore, family planning interventions should pay particular attention to both wives' and husbands' participation in family planning, while at the same time further educating married women and men on specific methods of contraception and their possible side effects. Moreover, a considerable amount of child death mainly boy child linking with boy sex preference reflects family planning interventions to see the ways beyond only for contraceptive purpose.

Acknowledgments

We would like to forward our gratitude to Jimma University, college of Public Health and Medical Sciences and Ghent University. Our special thanks goes to the supervisors, data collectors and respondents, the zonal health department and health center staffs. All authors read and approved the final manuscript.

Author Contributions

Critically reviewed drafts of the report: TT GC SL WK EL MT OD. Conceived and designed the experiments: TT MT GC SL. Performed the experiments: TT. Analyzed the data: TT OD. Wrote the paper: TT OD.

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Volume 19 Supplement 1

Sexual and Reproductive Health in Ethiopia: Gains and Reflections Over the Past Two Decades

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Published: 13 June 2022

Two decades of family planning in Ethiopia and the way forward to sustain hard-fought gains!

Mengistu Asnake Kibret 1 &
Lia Tadesse Gebremedhin 2

Reproductive Health volume 19 , Article number: 124 ( 2022 ) Cite this article

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Family planning (FP) is a human right, and ensuring women’s access to FP is central to protecting the health and wellbeing of mothers and children. Over the past two decades, Ethiopia has made FP service more widely available, increasing the contraceptive prevalence rate from 8% in 2000 to 41% in 2019. This remarkable fivefold increase can be attributed to the country’s overall development, including investment in education (particularly for girls) and reduction in child marriage, as well as the adoption and implementation of several enabling FP policies and strategies. In Ethiopia, achieving universal access to sexual and reproductive health care services, information, and education, including FP, by 2030 means enhancing these effective government policies and programs. Achieving universal access requires increasing financial resources, including domestic financing through greater government commitment for commodity security and program implementation; strengthening public–private partnerships; and improving service delivery for populations that are hard to reach and/or in humanitarian crisis. The persistence of equity gaps due to regional and/or sociodemographic disparities and the low quality of FP service delivery challenge our progress in Ethiopia. The papers included in this supplement provide additional detail on the overall progress described in this commentary and highlight focal areas for improvement in responding to unmet needs. Current policies and services must adapt, maintain, and build upon these gains and focus on targeted actions in areas identified for improvement. We must sustain the hard-fought gains of the past decades and help shape the prosperous future we advocate for in our society by 2030 and beyond—Leaving No One Behind.

Introduction

Family planning (FP) is a human right, and ensuring women’s FP access is central to protecting the health and wellbeing of mothers and children. The Constitution of the Federal Democratic Republic of Ethiopia Article 35(9) clearly sets forth a woman’s right to FP, stating that “[t]o prevent harm arising from pregnancy and childbirth and in order to safeguard their health, women have the right of access to family planning education, information and capacity” [ 1 ].

Although the 1994 constitution set forth a right to family planning, prior to 2000, the FP program in Ethiopia suffered from a shortage of trained personnel, limited contraceptive commodity supplies, and inadequate supervisory support and monitoring systems: all impacted access to and quality of service provision, evidenced by a low contraceptive prevalence rate [ 2 ]. However, over the past two decades, Ethiopia has made the remarkable achievement of increasing the contraceptive prevalence rate from 8% in 2000 [ 3 ] to 41% in 2019 [ 4 ]. This fivefold increase can be attributed to the country’s overall development, including investment in education (particularly for girls) and reduction in child marriage, as well as the adoption and implementation of several enabling FP policies and strategies. Policies that support FP services were anchored largely on the principles of the 1987 Safe Motherhood Initiative [ 5 ] and the Millennium Development Goals (MDGs) [ 6 ]. More recently, Ethiopia’s FP2020 commitment, made at the 2012 London Summit on Family Planning, further shaped the national FP strategies [ 7 ].

Starting in the early 1990s, the government of Ethiopia worked to shape an enabling environment for prioritizing FP services through various sectoral reforms [ 8 , 9 , 10 , 11 , 12 , 13 , 14 ]. In the late 1990s and early 2000s, the government implemented these different sectoral reforms and specific policies by developing different strategic documents. Leaders established a cornerstone policy, the Ethiopian flagship health extension program (HEP) [ 15 , 16 ]. HEP built on the experience of community-based FP programs implemented by international and local nongovernmental organizations (NGOs) in the late 1990s. Among them, the Family Guidance Association of Ethiopia and Consortium of Reproductive Health Associations played major roles in providing services and advocating for better policies and strategies [ 2 ]. These NGO-led programs laid the foundation to expanding women’s and girls’ access to FP information, counseling, and services in Ethiopia. However, the high dropout rates of community volunteers, lack of established incentive mechanisms, and resource scarcity led NGOs to phase out many community-based FP programs [ 17 , 18 , 19 ]. The programs’ experience, however, informed HEP, which has been instrumental in accelerating progress to meet the country’s MDGs [ 20 ]. HEP was also critical to increasing the uptake of long-acting reversible contraceptives [ 21 ]. Innovative service delivery approaches that include social marketing and using a network of private sector outlets also contribute to increasing access and responding to unmet needs [ 22 , 23 ].

The Ethiopian government’s decisions in 2007 to remove the tax levied on contraceptives [ 24 ] and empower the Ethiopian Pharmaceutical Supply Agency to procure and distribute contraceptives facilitated contraceptive supply and access [ 25 ]. At the same time, the government also broadened the resource base by increasing domestic financial resources allocated to the FP program: the annual allocation to the FP budget has continued to grow over the last decade. The country’s FP program, however, still largely depends on external resources [ 26 ]. Advocates must push for continued increase of government financial commitments to FP and reproductive health programs.

The United Nations agenda on Leaving No One Behind is adopted as the vision, promise, and commitment of the Ethiopian government’s 2030 Agenda and the SDGs [ 27 , 28 ]. In Ethiopia, achieving universal access to sexual and reproductive health care services, information, and education, including FP, by 2030 means enhancing these effective government policies and programs. Achieving universal access requires increasing financial resources, including domestic financing through greater government commitment for commodity security and program implementation; strengthening public–private partnerships; and improving service delivery for populations that are hard to reach and/or in humanitarian crisis [ 29 ].

Two challenges block further FP progress in Ethiopia: the persistence of equity gaps due to regional and/or sociodemographic disparities and the low quality of FP service delivery. Government agencies should fine tune their growth and development policies to close these gaps and ensure access to quality services for the entire population, in particular youths. The political commitment to incorporate FP into the development arena, as demonstrated in the health sector transformation plan and Ethiopia’s other national development plans, will help address this unfinished agenda. In addition, improving the quality of FP service delivery, expanding effective models of service integration, and reaching hard-to-reach population groups or subgroups and people in humanitarian crisis will further enhance the success of FP programs.

The papers included in this supplement provide additional detail on the overall progress described in this commentary and highlight focal areas for improvement in responding to unmet needs. These areas include child marriage in hot-spot areas, gender inequality, adolescent reproductive health, improving quality of care, and counteracting widespread individual and community misperceptions and beliefs. The emergence of the COVID-19 pandemic and other human-produced and natural disasters in the past years might affect the advancement of the overall achievements gained so far. We must adapt our work to maintain these gains. In addition, targeted actions in areas identified for improvement will sustain the hard-fought gains in the past decades and help shape the prosperous future we advocate for in our society by 2030 and beyond—Leaving No One Behind.

Availability of data and materials

Data sharing is not applicable to this article because no data sets were generated or analyzed during the current study.

Abbreviations

Family planning

Health extension program

Millennium development goal

Nongovernmental Organization

Sustainable development goals

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This article has been published as part of Reproductive Health Volume 19 Supplement 1 2022: Sexual and Reproductive Health in Ethiopia: Gains and Reflections Over the Past Two Decades. The full contents of the supplement are available at https://reproductive-healthjournal.biomedcentral.com/articles/supplements/volume-19-supplement-1 .

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Kibret, M.A., Gebremedhin, L.T. Two decades of family planning in Ethiopia and the way forward to sustain hard-fought gains!. Reprod Health 19 (Suppl 1), 124 (2022). https://doi.org/10.1186/s12978-022-01435-5

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Knowledge and Attitude Towards Family Planning Among Women of Reproductive Age in Emerging Regions of Ethiopia

Affiliations.

1 Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.
2 Saint Paul's Hospital Millennium Medical College, Research Office, Addis Ababa, Ethiopia.
3 Public Health Department, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.
4 Federal Ministry of Health, Ministry's Office, Addis Ababa, Ethiopia.
5 School of Public Health, Haramaya University, Harar, Ethiopia.
6 Private Consultancy Practice, Addis Ababa, Ethiopia.
PMID: 33177832
PMCID: PMC7649215
DOI: 10.2147/JMDH.S277896

Background: Despite recent improvements in the use of contraceptives amongst married women in Ethiopia, the utilization rates are still far below the national figures in the emerging regions of the country. Therefore, there is a need to assess the level of knowledge and attitudes towards family planning, and associated factors among reproductive-age women in the four emerging regions of Ethiopia.

Methods: A community-based cross-sectional study was conducted among 2891 reproductive-age women from 01 to 30 June, 2017. The data were collected by open data equipped tablets with kit software using structured questionnaire. The collected data were exported to STATA version 14 for analysis. Knowledge and attitude were assessed using tools containing 12 and 9 questions, respectively. Mean scores were used as cut-off points. Internal consistency of the tool was checked using Cronbach alpha coefficient, and it was 0.87 for knowledge and 0.78 for attitude questions. Bivariate and multivariate analyses were done, and statistical significance was declared at p-value ≤ 0.05.

Results: Less than half, 1254 (43.4%), of the participants had good knowledge and 1511 (52.3%) had favorable attitude towards FP. Positive predictors of good knowledge of family planning were: being from Benishangul-Gumuz region, urban residence, older age, high level of education, being Christian and merchant, high household monthly income, and listening/watching radio/TV. On the other hand, high family size and ideal desired children were negative predictors. For a favorable attitude, the positive predictors include older age, high level of partner education, listening/watching radio/TV, being from BG region and having a good knowledge of FP. Desiring high number of ideal children and being a student by occupation were negatively associated with a favorable attitude.

Conclusion: The study revealed that significant number of women had poor knowledge and attitude towards FP. Multiple socio-demographic factors contributed to knowledge and attitude of FP. Therefore, the health sectors of the regions and other stakeholders should strengthen the health extension program to disseminate messages related to FP to improve the knowledge and attitude of women.

Keywords: Ethiopia; attitude; emerging regions; family planning; knowledge; reproductive-age women.

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Open access
Published: 23 May 2023

Quality of family planning services and associated factors among reproductive age women attending family planning unit at public health facilities in Dire Dawa, Eastern Ethiopia, 2021

Legesse Abera 1 ,
Ezira Ejigu 2 ,
Mickiale Hailu 3 ,
Daniel Tadesse 3 &
Abdu Omer 1

Contraception and Reproductive Medicine volume 8 , Article number: 33 ( 2023 ) Cite this article

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Introduction

Improving the quality of care has been a necessary goal for family planning programs worldwide. Even though extensive work has been done, the contraceptive prevalence rate is still low (41% in Ethiopia, 30.5% in Dire Dawa) and the unmet need for contraception is high (26%) in Ethiopia. Moreover, quality of care in family planning services has an important role in increasing coverage of services and program sustainability. Therefore, the objective of this study was to assess quality of family planning services and associated factors among reproductive age women attending family planning unit in public health facilities in Dire Dawa, Eastern Ethiopia.

A facility-based cross-sectional study was conducted among reproductive-age women attending a family planning unit in Dire Dawa, Eastern Ethiopia, from September 1–30/2021. A total of 576 clients were selected by systematic random sampling and interviewed using a pre-tested structured questionnaire. SPSS version 24 was used to analyze the data, which included descriptive statistics, bi-variable and multivariable logistic regression analyses. To determine the presence of an association between dependent and independent variables, AOR, P-value 0.05, and 95% CI were used.

A total of 576 clients participated in the study and provided a response rate of 99%. The overall satisfaction of clients with FP services was 79%[95% CI:75.2%, 82.9%]. Having primary education (AOR = 2.11, 95% CI(1.11–4.24), convenient facility opening hours (AOR = 3.13, 95% CI (2.12–5.75), maintaining privacy (AOR = 4.1, 95% CI(2.50–8.12), demonstrating how to use F/P method (AOR = 1.98, 95% CI (1.01–5.20), and discussing F/P issues with husbands (AOR = 5.05, 95% CI: 3.33–7.64) were positively significantly associated with client satisfaction.

Conclusion and recommendation

This study revealed that about four-fifth of the clients was satisfied with the service they received. Clients’ education, facility opening hour, maintained privacy, discussion with husband, and demonstration of how to use the methods were associated with client satisfaction. Therefore, health facility heads should improve facility opening hour. Health care providers should maintain client privacy every time, and should consistently utilize information, education, and communication materials during consultation sessions by giving more attention to client who has no education. Partner’s discussion on family planning issues should also be encouraged.

Family planning is the ability of an individual or couple to decide when to have children, how many children they desire in a family and how to space their children. It is a means of promoting the health of women and families [ 1 ]. Family planning services are unique in providing the means for couples to space or limit their births and stabilize the world's population [ 2 ].

Studies indicate that maternal, infant and child mortality rates are high wherever fertility is high. In Ethiopia, the maternal mortality rate estimates to be 412 per 100,000 live births, with more than 50% resulting from unsafe abortion, thus making Ethiopian women at the highest reproductive risk in the world [ 3 ]. The Ethiopian population policy, adopted in early 1993, aims to reduce the total fertility rate, reduce morbidity and mortality, and raise the contraceptive prevalence rate to a national average of 44% by 2015 [ 4 ].

On the other hand, poor quality of care and distrust and alienation created by differences in age, gender, perceived competency and hostility of providers were responsible for many women switching services or stopping use of family planning services entirely. Provision of quality Family Planning service has become the intervention of choice to slow the demographic explosions and part of strategies to reduce the high maternal and child mortality rates. Evidence also showed that low-quality Family Planning service being provided at service delivery points contributed to lessened service utilization [ 5 ].

Improving the quality of Family Planning services offers many benefits; information and service will be accessible, clients will make informed decisions, and the public will have a more positive view of health care and its providers. Thus, it is hypothesized to decrease fertility (unplanned population growth) mainly by increasing acceptance, continuation, and hence the prevalence of contraceptive use [ 6 , 7 ].

Research shows that good quality offers practical benefits to Family Planning clients and programs. These include: -Safety and effectiveness: -Good qualities make contraception safer and more effective. If poorly delivered, some family planning services can cause infection, injuries, and in rare cases, death. Poor services also can lead to incorrect, inconsistent, or discontinued contraceptive use [ 8 ].

In this study, the Donabedian model was used . Avian Donabedian defined quality of care as “the application of medical science and technology in a manner that maximizes the benefits to health without correspondingly increasing the risk” [ 9 ]. His model was developed considering quality of care could involve several formulations depending on where the healthcare system is located. It was intended to assess quality of care in various health services including Family Planning. He identified quality of care as a linear model comprising three components — structure, process, and outcome.

The structure dimension includes all factors affecting the conditions of care-giving such as budget, staff training, reward systems, payment methods, facilities and equipment. The process dimension focuses on what is happening “inside the door” where the provider communicates with the client. The last component of quality is the outcome following provider and client interaction in the clinic. These three parts are interlinked as good structure increases the likelihood of good process, and good process increases the likelihood of a good outcome. Therefore, since client satisfaction considered as one of the desired outcomes of health care, we have used client satisfaction as the outcome variable in this study [ 9 , 10 ].

Even though different stakeholders have done other work, like increasing the number of health institutions and trained health workers so far, detailed information on the quality of family planning services remains surprisingly limited. In the absence of detailed information on the quality of services, policy discussions on this issue have remained general and concrete recommendations for improving services elusive [ 11 ]. Therefore, this study aims to assess the quality of Family Planning services in all dimensions and explore factors affecting the quality of family planning services in Dire Dawa Administration, Eastern Ethiopia. This will help provide evidence-based data to improve and increase Family Planning services quality, utilization and coverage, which in turn improve maternal and child health.

Study setting and design

A facility-based cross-sectional study was conducted from September 1–30/2021, in Dire Dawa, Eastern Ethiopia. Dire Dawa is one of the known and ancient cities in Eastern Ethiopia, which is found around 515 km far from Addis Ababa. Somali Regional State borders it in the east, west and north, and the Oromia Regional State in the south and east. Dire Dawa has a total area of 1,558.64 square kilometers with an estimated density of 237.2 people per square kilometer. The administration's total population of 453,000 in 2016 comprised 227,000 males, 226,000 females and 94,187 childbearing-age women. The total fertility rate of the administration is 3.4 child/ woman and annual population growth rate of 2.9%.

The majority of the population (68%) is urban dwellers [ 12 ]. The potential health service coverage of Dire Dawa was 100%, with two governmental hospitals, 15 health centers, and 34 health posts, all providing Family Planning services [ 13 ].

Study population and sampling procedure

The study population includes women of the reproductive age group who visited the family planning services unit at selected public health facilities (2 hospitals and 6 health centers) in Dire Dawa Administration in 2021.

Overall, we recruited 582 family planning users for exit interviews. A standard single population proportion formula was used to calculate the sample size with the assumption of Z 2 α/2 = is (1.96 to be 95% confident level), P = 78% of family planning users satisfied [ 14 ], d = is margin of error to be tolerated and taken as 5%, 10% non-response rate and design effect 2. A total of 160 consultation sessions were observed using an observation checklist, and eight public health facilities were checked for logistics related to family planning services.

Stratified and multistage sampling techniques were employed. Public health facilities in Dire Dawa were identified as rural and urban. Then, using simple random sampling, eight health facilities (4 urban and 4 rural Kebele’s) were selected. Again, the calculated sample size was proportionally allocated to each health facility chosen according to the number of client flows from the previous year of a similar month. Finally, study subjects were selected for the study by systematic random sampling technique (k = N/n, 18,080/12 = 1506/582 = 2.6 = 3). The total number of client flow in the selected health facilities was summed up and divided by the sample size required.

Outcome variable

The dimension employed to measure quality Family Planning in this study was the last component of quality which is the outcome which was measured by satisfaction following provider and client interaction. The main variables under the utilized dimension (outcome) were satisfied and not satisfied.

The theoretical domains behind employing this dimension is that: The quality of care provided in Family Planning service delivery can impact Family Planning use in two ways. Firstly, when clients receive a good quality of care at their first visit, they are more likely to remain in the Family Planning program [ 15 ]. Secondly, good quality of care can also result in positive outcomes as clients' satisfaction [ 15 , 16 ].

Measurement

Client satisfaction

This is clients’ opinion of care received from Family Planning services provider and is acknowledged as an outcome indicator of quality of care/service.

✓ During analysis the five Likert scale re-categorized/dichotomized as agree and disagree.

✓ Clients were satisfied if they agree in greater or equal to the mean score of the items (there were 15 items).

✓ Clients were not satisfied if they disagree in greater than the mean score of the items (there were 15 items) [ 14 , 17 ].

Data collection tool and procedures

A pre-tested structured interview-administered questionnaire was partly adapted from the literature and some wording or phrasing utilized was modified according to the study's objectives. The questionnaire was first prepared in English and then translated to Amharic and Somali languages, and then back translation was made to see the consistency of the questionnaires. The collected data were also cross-checked daily for its consistency and completeness. Data quality was assured by giving training and appropriate supervision for data collectors. The principal investigator carried out the overall management.

Data processing and analysis

The collected data were cleaned, edited, coded, and entered into Epi Data version 3.1 and exported to SPSS version 24 for analysis. Descriptive statistics such as frequencies, proportions, and summary statistics were used to describe the study population with relevant variables. Multicollinearity was checked between each independent variable by using Variance Inflation Factors (VIF) to control possible confounding factors. Both bi-variable and multivariable logistic regression analyses were computed. First, bivariate logistic regression analysis was used to assess the presence of association between dependent and independent variables. Then, variables with p-value < 0.25 were screened for multivariable logistic regression and final model fitness was checked by Hosmer–Lemeshow goodness of fit test. Adjusted odds ratios, P-value < 0.05 with 95% CI were used to declare the significance and level of association between the dependent and independent variables.

Socio-demographic characteristics of respondents

A total of 576 clients of family planning users were successfully interviewed immediately after receiving care in eight (8) public health facilities and gave a response rate of 99%. As shown in Table 1 , 378 (65.6%) were repeat clients, while 198 (34.4%) were new clients. The majority of participants, 253 (43.9%) were between 20- 24 years old with a mean age of 25 years (SD + 4.5). (Table 1 ).

Availability and functionality of logistic supplies for family planning services

Eight family planning service delivery points (health facilities) were audited for the availability and functionality of family planning services logistics, and supplies that were crucial to function effectively and could affect the quality of care provided.

Satisfactory facility environment

Among eight health facilities, only five had a clean water supply, and 50% had toilets with poor sanitation. In three of the health facilities, there was a shortage of staff assigned to work in family planning services and in all health facilities there was a shortage of trained providers. All health facilities' official working days and hours were from Monday to Friday from 8:30 am to 5:30 pm except for lunch time (12:30 am-8:00 pm). All health facilities have an examination couch and clients seating and offer visual privacy but not auditory privacy during a pelvic examination, IUCD insertion or during consultation time. Based on the findings, the facility environment in our study area was satisfactory.

Availability of minimum equipment to offer Family Planning services

The result showed blood pressure measurement apparatus, weight scale, and stethoscope were available in all health facilities, but stethoscopes were shared with other departments in 3 (37.5%) of health facilities. Uterine sound, tenaculum, speculum, and scissors were unavailable in 2 (25%) facilities. All health facilities had essential disposable items like needles, syringes and gloves. All health facilities had laboratory units, but 2 (25.0%) of health facilities had not been performing pregnancy tests because of the absence of kits for pregnancy tests. Hence, all health facilities fulfilled the minimum equipment to offer family planning services.

Availability of Family Planning contraceptive supplies

The assessment result indicated that combined pills, progestin-only pills, Depo Provera, Implanon and condoms were available in all setups. However, IUCD was only available in three health facilities. The procedure for tubal legation and vasectomy was carried out in two hospitals.

As shown in Fig. 1 ; Client exit interviews showed the majority, 209 (36.3%) of clients were using/received Implanon, 196 (34.0%) of clients were using injectable (Depo-Provera), 130 (22.6%) of clients were using pills, 29 (5.0%) using a condom and only 12 (2.1%) using IUCD (Fig. 1 ). All of the health facilities had recording systems for received and dispensed FP commodities and adequate storage facilities. Stores were protected from sun, rain, wet, and rats in all health facilities. Based on the above information, the minimum standard of contraceptive supply is achieved.

Types of contraceptive methods frequently used by clients in assessing the quality of care in f/p services among public health facilities in Dire Dawa, Eastern Ethiopia, September 2021

Availability of reproductive health guidelines and FP IEC materials

Only 4 (50%) health facilities had a copy of Ethiopian Minister of Health (EMOH) guideline of family planning and reproductive health services and achieved the requirement. All health facilities had at least one information education and communication (IEC) material but not three at a time. Regarding IEC materials during consultations, 35 (21.9%) were used flip charts, 28 (17.5%) were displayed samples of contraceptives, brochures were used by 8 (5.0%) of clients and posters were used by 50 (31.3%) of clients. A combination of two or more IEC materials was used for 39 (24.4%) clients (Fig. 2 ).

Types of IEC materials frequently used by providers during client counseling/consultation time by observation among public health facilities in Dire Dawa, Eastern Ethiopia, September 2021

Appropriate constellation of services

By exit interview, the distance of clients’ homes from the service delivery was estimated by the clients themselves and 311 (54.0%) of clients were reported that they traveled less than 30 min, 201 (34.9%) of clients were traveled 30–60 min and 64 (11.1%) of clients were traveled more 60 min. Regarding the opening hours of health facilities, 452 (78.5%) of the clients agreed that the opening hour was convenient for them, and 124 (21.5%) of clients disagreed with opening hours. The median waiting time was 25 min and SD ± 20 min, ranging from 5 to 45 min. The waiting time of clients at the service delivery points before getting services, 503 (87.3%) of clients were reported that the waiting time was short, and 73 (12.7%) of clients were informed that the waiting time was long (Table 2 ).

Provider competency for provision of family planning services

As shown in Table 3 above, Four hundred seventy (81.6%) of the respondents reported that the provider explained how the method works. Almost all, 530 (92.0%) of the respondents reported that the provider demonstrated how to use the method, 455 (79.0%) of providers described possible side effects, 464 (80.6%) of providers explained what to do for side effects, 496 (86.1%) of providers told to their clients about the possibility of changing method and 473 (82.1%) of them mentioned when and where to go for supply or follow-up.

Client-provider interaction from client perspective

As shown in Table 4 ; 430 (74.6%) of clients reported that consultation time with the provider was about right (appropriate), 146 (25.4%) of clients were informed that the consultation time was short, and 52 (9.0%) of the clients were did not want to respond. Moreover, 527 (91.5%) of the clients reported that the provider was easily understandable, and 36 (6.3%) of the clients said that the provider was challenging to understand (Table 4 ).

Client satisfaction with family planning services provided

As Table 5 shows, among all Family Planning (FP) users interviewed, 517 (89.8%) were satisfied with FP counseling given by service providers, while 59 (10.2%) of them were not satisfied. The majority of the respondents were satisfied with the ease of getting Family Planning unit (89%).

Overall satisfaction of clients with family planning services was indicated that, 455 (79%) [95% CI: 75.2%, 82.9%] of the clients were satisfied with the service they received, and 69 (12.0%) of the clients were not satisfied (Table 5 ).

Factors associated with client satisfaction with family planning services

In bi-variable logistic regression analyses, client’s residence, educational status, facility opening hours, short waiting time, maintained privacy, having family planning discussion with husbands, sufficient consultation time, demonstration of how to use the methods, and proper explanation of side effects was significantly associated with client satisfaction.

In multivariable logistic regression analysis again, client education, the convenience of facility opening hours, maintained privacy, demonstrated of how to use the method, and having family planning discussions with husbands were significant associations with client satisfaction.

Clients with primary education were 2.11 times more likely satisfied with family planning services provided them than those with secondary education and above (AOR = 2.11, 95%CI (1.11–4.24). Clients who agreed that the facility opening hour was convenient for them were 3.13 times more likely satisfied than those who disagreed with the facility opening hour (AOR = 3.13, 95% CI (2.12–5.75).

Family planning users whose privacy was maintained during examination and procedure were four times more likely satisfied than those whose privacy was not maintained (AOR = 4.1, 95% CI (2.50–8.12). Clients who demonstrated how to use the method were 1.98 times more likely to be satisfied than those who were not demonstrated (AOR = 1.98, 95% CI (1.01–5.20).

Clients who had family planning discussions with husbands were five times more likely satisfied than those who had no family planning discussion (AOR = 5.05, 95% CI: 3.33–7.64) (Table 6 ).

It has been said that good quality family planning service helps individuals and couples to meet their reproductive health needs safely and effectively. Client satisfaction is essential to clients’ decisions to use and continue the service for their future. And it is a core indicator of the quality of service. This study showed that, the overall satisfaction of clients with Family Planning services was 79% [95% CI: 75.2%, 82.9%]. This finding is almost consistent with the studies conducted in Metu Karl Referral Hospital, South West Ethiopia (78%), Hosana (75%), Kenya (75.3%), and Nigeria (81%) [ 14 , 17 , 18 , 19 ]. The possible reasons for the similarity could be the perceived sufficiency of consultation, and low expectations of clients on Family planning of service at public health facility.

But the finding is higher than the finding of the studies conducted in Wonji Hospital, Ethiopia (42%), and Jijiga (41.7%) [ 20 , 21 ]. The possible explanation might be socio-demographic differences between the study populations in the above studies.

However, the result of our study is lower than studies conducted in Jimma zone, Southwest Ethiopia (93.7%), Senegal (84%) and Mozambique (85%) [ 22 , 23 , 24 ]. The possible reason for this discrepancy could be this study didn’t include the private and non-governmental health facilities compared to the above studies. Hence, the level of client satisfaction is expected to be higher in private health facilities [ 25 ].

Studies in the developing world have shown a clear link between patient satisfaction and various explanatory factors, among which service quality has been prominent. The finding of this study revealed that Clients with primary education were 2.11 times more likely to be satisfied than those with secondary education and above. This finding was consistent with a study conducted in Metu Karl Referral Hospital, South West Ethiopia [ 14 ]. The possible explanation could be that the more educated the clients, the more they expect quality services than the actual services provided.

The convenience of facility opening hours was a predictor of client satisfaction. Clients who agreed that the facility opening hour was convenient were 3.13 times more likely to be satisfied than those who disagreed with the opening hour. This finding is consistent with a study conducted in Hosanna town health facilities [ 17 ]. The possible explanation could be that the opening hour is convenient for clients; they receive the service early and utilize their time properly for other duties, increasing their satisfaction.

In this study, family planning users who were demonstrated how to use family planning of their choice were about two times more likely satisfied with the services compared to those who were not demonstrated. This finding is consistent with the studies conducted in Metu Karl referral Hospital, South West Ethiopia, Hosanna town, and Jimma zone, Southwest Ethiopia [ 14 , 17 , 24 ]. This finding might be related to the fact that the information provided and demonstrated during service contact enables clients to choose and use contraception, increasing their understanding of how to use the methods, thereby increasing client satisfaction. Clients' lack of information on how to use it results in a negative attitude towards methods whenever they experience certain side effects. This might lead to dissatisfaction and the client might discontinue the chosen family planning method.

This study again revealed that Family planning users whose privacy was maintained during examination and procedure were four times more likely satisfied than those whose privacy was not maintained. This finding is in line with the study conducted in Hosanna town [ 17 ]. The possible explanation could be privacy is very important culturally and they consider it as the provider respecting their dignity, which increases their satisfaction.

Studies showed that having a family planning service discussion with the husband is a principal factor leading to a high rate of satisfaction and program and method continuation [ 26 ]. In this study, clients who had family planning discussions with husbands were five times more likely satisfied than those who did not discuss with their husbands. This result was similar to the Jimma studies [ 27 ]. This could be because as a free discussion between partners, women can easily meet their needs and free talk with providers, enhancing satisfaction.

Long waiting time is a principal factor leading to a high rate of program and method discontinuation [ 26 ]. In this study, 87.3% of clients agreed that the waiting time was acceptable (short), which was a similar finding to the studies conducted in Bangladesh (71.8%) of clients were satisfied [ 28 ]. This is far higher than the USAID analysis on the quality of family planning report from Ghana, Kenya, and Tanzania, in which 42.1% and 69% of clients got service within the acceptable waiting time, respectively [ 25 ]. But lower than the study in Jimma (92.4%) [ 27 ]. This variation could be because of the difference in facilities working culture, client flow and the recent reform implementation in the current study setting.

Welcoming or greeting clients in the first contact at service delivery points enhances the interaction as it has emotional contents of exchange between provider and clients. In this study, 130 (81.3%) clients were provided a warmly greeted in a respectful and friendly way by their care providers. This result is better than the study conducted in Jimma (65.3%) of the providers welcomed their clients [ 24 ]. This indicates most of the family planning providers are not consistently working as per the guideline, which compromises the quality of FP services. This might be due to provider neglect, shortage of time, or client overflow.

Privacy is one of the main criteria for assessing care quality [ 29 ]. In our study, 536 (93.0%) of the clients responded that their privacy was maintained, but in observation, privacy was maintained in (78.1%) of clients. This study result is better than the study conducted in northwest Ethiopia (33.7%) [ 30 ]. But in our study, similar to the above study, auditory privacy was not maintained in around three-fourths of observed clients. This low auditory privacy could result from a lack of separate room for FP services.

In conclusion, quality is rapidly becoming a global issue and concern to both the provider and the users of health services. This study identified that about four-fifth of the clients were satisfied with the service they received. Having education, convenience of facility opening hours, maintaining privacy during examination and procedure, demonstrating how to use FP methods were positively associated with client satisfaction with family planning service. Therefore, health facility heads should improve facility opening hour. Health care providers should maintain client privacy every time, and should strengthen the utilization of IEC materials during consultation and demonstration sessions by giving more attention to client who has no education. Partner’s discussion on family planning issues should also be encouraged.

Availability of data and materials

Data related to this manuscript is available on the hand of corresponding author and will be obtained under a reasonable request.

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Acknowledgements

First and for most, we would like to thanks Dire Dawa University research affair directorate and the college of medicine and health sciences for providing us the opportunity to conduct this research. Secondly, we would like to thanks all data collectors and facilitators for their valuable contribution in collecting and facilitating data collection. Lastly but not least we would like to thanks study participants to take part in this study.

This work has been funded by Dire Dawa University. But this organization did not involve in designing, analysis, critical review of its intellectual content, preparation of the manuscript and the budget funded by this organization did not include for publication.

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LA is the main author and he was made substantial contributions from the start of the research idea to proposal development, data collection, analysis and interpretation of data and preparation of the manuscript. EE, MH, DT and, AO: were participated in proposal development, data analysis and preparation of the manuscript for publication. All authors read and approved the final version of the manuscript.

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Abera, L., Ejigu, E., Hailu, M. et al. Quality of family planning services and associated factors among reproductive age women attending family planning unit at public health facilities in Dire Dawa, Eastern Ethiopia, 2021. Contracept Reprod Med 8 , 33 (2023). https://doi.org/10.1186/s40834-023-00231-1

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Knowledge, attitude and practice towards family planning among reproductive age women in a resource limited settings of Northwest Ethiopia

Ayele Semachew Kasa ORCID: orcid.org/0000-0003-3320-8329 1 ,
Mulu Tarekegn 1 &
Nebyat Embiale 2

BMC Research Notes volume 11 , Article number: 577 ( 2018 ) Cite this article

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To assess the knowledge and attitude regarding family planning and the practice of family planning among the women of reproductive age group in South Achefer District, Northwest Ethiopia, 2017.

The study showed that the overall proper knowledge, attitude and practice of women towards family planning (FP) was 42.3%, 58.8%, and 50.4% respectively. Factors associated with the practice of FP were: residence, marital status, educational status, age, occupation, and knowledge, and attitude, number of children and monthly average household income of participants. In this study, the level of knowledge and attitude towards family planning was relatively low and the level of family planning utilization was quite low in comparison with many studies. Every health worker should teach the community on family planning holistically to increase the awareness so that family planning utilization will be enhanced. Besides, more studies are needed in a thorough investigation of the different reasons affecting the non-utilizing of family planning and how these can be addressed are necessary.

Introduction

Family planning (FP) is defined as a way of thinking and living that is adopted voluntary upon the bases of knowledge, attitude, and responsible decisions by individuals and couples [ 1 ]. Family planning refers to a conscious effort by a couple to limit or space the number of children they have through the use of contraceptive methods [ 2 ].

Family planning deals with reproductive health of the mother, having adequate birth spacing, avoiding undesired pregnancies and abortions, preventing sexually transmitted diseases and improving the quality of life of mother, fetus and family as a whole [ 3 , 4 ].

The Federal Ministry of Health (FMOH) has undertaken many initiatives to reduce maternal mortality. Among these initiatives, the most important is the provision of family planning at all levels of the healthcare system [ 5 , 6 ]. Currently, short-term modern family planning methods are available at all levels of governmental and private health facilities, while long-term method is being provided in health centers, hospitals and private clinics [ 6 ].

The study done in Jimma Zone, Ethiopia showed that good knowledge on contraceptives did not match with the high contraceptive practice [ 7 ]. Different researchers showed that the highest awareness but low utilization of contraceptives making the situation a serious challenge [ 8 , 9 ].

Most of reproductive age women know little or incorrect information about family planning methods. Even when they know some names of contraceptives, they don’t know where to get them or how to use it. These women have negative attitude about family planning, while some have heard false and misleading information [ 10 , 11 ] and the current study aimed in assessing the knowledge, attitude and practice (KAP) of FP among women of reproductive age group in South Achefer District, Northwest Ethiopia.

Methods and materials

Study design and setup.

A community-based cross-sectional study was conducted in South Achefer District, Amhara Region, Northwest Ethiopia from March 01–April 01, 2017. Systematic sampling technique was used to recruit the sampled reproductive age women (15–49 years old). Based on the number of households obtained from the Kebele’s (Smallest administrative division) health post, the sample size (389) was distributed to the households. The sampling interval was determined based on the total number of 4431 households in the kebele. The first household was taken by lottery method and if there were more than one eligible individual in the same household one was selected by lottery method.

The data collection questionnaire was developed after reviewing different relevant literatures. The questionnaire, first developed in English language and then translated to Amharic (local language). Pretest was done on 5% of the total sample size at Ashuda kebele. After the pretest, necessary modifications and correction took place to ensure validity.

Those reproductive age women who answered ≥ 77% from knowledge assessing questions were considered as having good knowledge, those women who scored ≥ 90% from attitude assessing questions were considered as having favorable attitude and those women who scored ≥ 64% from practice assessing questions were considered as having good over all practice towards FP [ 7 ].

Data processing and analysis

The collected data was cleaned, entered and analyzed using SPSS version 21 software. Descriptive statistics were employed to describe socio-demographic, knowledge, attitude and practice variables. Chi squared (χ 2 ) test was used to determine association between variables. Associations were considered statistically significant when P-value was, < 0.05.

Socio-demographic characteristics of participants

The response rate in this study was 97.9%. Among 381 participants included, 185 (49%) were from rural villages. About 47% of the participants were illiterate and 52% were completed primary education. The monthly household income of the majority (42.5%) of the participants was between 1000 and 3000 Ethiopian birr. Regarding the family size of the participant’s, majority (48.3%) of them had ≥ 3 children.

The mean age of participants was 29.7 ± 6.4. Two hundred forty six (64.6%) and 133 (34.9%) were house wife’s and farmers respectively by their occupation. Almost two-third (65.4%) of participants were married, 24.9% were divorced by their marital status (Table 1 ).

Knowledge status of participants

All of participants ever heard about family planning methods. The major sources of information were from health workers (57.5%) and radio (41.5%). Regarding perceived side effects of using family planning, 13.1%, 24.9%, 9.7% and 52.2% of participants were responded heavy bleeding, irregular bleeding, an absence of menstrual cycle and abdominal cramp respectively were mentioned as a side effect. Among those who have children; 24.6% gave their last birth at home and 75.5% gave their last birth at the health institution. Regarding the overall knowledge of study participants, 161 (42.3%) had good knowledge towards family planning and the rest 220 (57.7%) had poor knowledge.

Attitude status of participants

The majority (88.5%) of the respondents ever discussed on family planning issues with their partners and wants to use it in the future. About 24.5% of the participants reported that they believe family planning exposes to infertility. Almost 23 (22.8%) of study participants reported that using family planning contradicts with their religion and culture. Regarding the overall attitude, 224 (58.8%) of the participants had favorable attitude and 157 (41.2%) had unfavorable attitude towards family planning.

Practice on family planning

Three fourth (75.3%) of study participants ever used contraceptive methods. The main types were pills (7.4%) and injectable (77.2%). The most common current reasons for not using were a desire to have a child (53.2%) and preferred method not available (46.8%). Almost half (50.4%) of study participants had good practice and the rest 49.6% had poor practice.

Factors associated with family planning practice

Study participants’ religion was not included in the analysis due to lack of variance, since almost all (99.2%) of participants were Orthodox Christians by their religion.

Women who had good knowledge were more likely to practice FP than those who have low knowledge (χ 2 = 117.995, d.f. = 1, P < 0.001) and women who had favorable attitude towards FP were more likely to practice FP (χ 2 = 106.696, d.f. = 1, P < 0.001). It was also seen that residence, age, educational status, occupation, marital status, number of children and monthly income of the were significantly associated with the practice of FP [(χ 2 = 69.723, d.f. = 1, P < 0.001), (χ 2 = 104.252, d.f. = 2, P < 0.002), (χ 2 = 119.264, d.f. = 1, P < 0.001), (χ 2 = 41.519, d.f. = 1, P < 0.001), (χ 2 = 39.050, d.f. = 1, P < 0.001), (χ 2 = 144,400, d.f = 3, P < 0.001) and (χ 2 = 179.366, d.f. = 1, P < 0.002)] respectively (Table 2 ).

Increasing program coverage and access of family planning will not be enough unless all eligible women have adequate awareness for favorable attitude and correctly and consistently practicing as per their need. Increasing awareness/knowledge and favorable attitude for practicing FP activities at all levels of eligible women are strongly recommended [ 6 ].

The results of the present study showed that 42.3% of study participants had good knowledge, 58.8% had favorable attitude, and 50.4% had good practice towards family planning. This finding was lower than a study conducted in Jimma zone, Southwest Ethiopia [ 7 ], Sudan [ 9 ], Tanzania [ 12 ] and another study done in Rohtak district, India [ 13 ]. The difference may be due to; studies done in Jimma zone, Sudan, Tanzania and Rohtak district involve only those coupled/married women. Married women might have good knowledge and attitude for practicing family planning. But in the current study, all women of reproductive age group regardless of their marital status were studied and this may lower their knowledge and attitude.

The current study showed that, 50.4% of reproductive age women were practicing family planning which was almost in line with a study done in Cambodia [ 14 ] and higher than a study done in rural part of Jordan [ 15 ] and India [ 16 ]. But it was lower than studies conducted in Jimma zone, Ethiopia [ 7 ], Rohtak district, India [ 13 ], urban slum community of Mumbai [ 17 ] and in Sikkim [ 18 ] in which 64%, 62%, 65.6% and 62% of participants respectively used family planning. The difference might be due to that study participants in Jimma zone, Rohtak and Mumbi were relatively residing in large city/town and this may help them to have a better access for family planning compared to the study done in South Achefer District.

In the current study, urban residents were more likely to use family planning methods (71.4%) than their rural counterparts (28.1%). This finding was in line with the findings from Ethiopian Demographic Health Survey (EDHS) [ 2 ]. This might be due to the reason that urban residents are more aware of family planning and hence practicing better.

It has also found that women who completed primary & secondary education were practicing family planning than those who were uneducated (77.1% and 20.6%) respectively. This finding was in line with a study done in Jimma, Ethiopia [ 19 ]. This might be due to the fact that women who were able to read and write would think in which FP activities are useful to be economically, self-sufficient and more likely to acquire greater confidence and personal control in marital relationships including the discussion of family size and contraceptive use.

This study showed that, age of the study participants had an association with practicing FP. Those reproductive age women’s whose age > 30 years were practicing family planning better than those whose age < 18 years. This finding was in line with a study done in India [ 20 ]. This might be due to the reason that, when age increases mothers awareness, attitude and practice towards family planning may increase. In addition, as age increases the chance of practicing sexual intercourse increases and as a result they would be interested to utilize family planning in one or another way.

It has also revealed that women’s average monthly household income has an association with their FP practicing habit. Those study participants whose average monthly income < 1000 ETB were using FP better than whose average monthly income > 3000 ETB. This is might be because those relatively who had better income may need more children and those with low income may not want to have more children beyond their income.

The current study also showed that knowledge and attitude of reproductive age women were related to FP utilization. Those reproductive age women who had good knowledge were utilized FP better than from those who were less knowledgeable. Those participants with favorable attitude were practicing better than those who had unfavorable attitude. This is might be due to the fact that knowledge and attitude for specific activities are the key factors to start behaving and maintaining it continuously.

Conclusion and recommendation

The level of knowledge and attitude towards family planning was relatively low and the level of family planning utilization was quite low in comparison with many studies.

Study participant’s residence, marital status, educational level, occupation, age, knowledge, attitude, their family size and their monthly average income were associated with FP utilization habit of reproductive age women.

Every health worker should teach the community on family planning holistically to increase the awareness so that family planning utilization will be enhanced.

Besides, more studies are needed in a thorough investigation of the different reasons affecting the non-utilizing of family planning and how these can be addressed are necessary.

Limitation of the study

As the data were collected using interviewer administered questionnaire, mothers might not felt free and the reported KAP might be overestimated or underestimated.

We do not used qualitative method of data collection to gather study participant’s internal feeling about family planning, so that triangulation was possible. In addition, barriers for utilizing contraception not addressed.

Abbreviations

Ethiopian Demographic Health Survey

Ethiopian birr

Federal Ministry of Health

family planning

knowledge, attitude and practice

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Authors’ contributions

AS: approved the proposal with some revisions, participated in data analysis. MT: wrote the proposal, participated in data collection analyzed the data and drafted the paper. NE: approved the proposal with some revisions, participated in data analysis. All authors read and approved the final manuscript.

Acknowledgements

We are very grateful to all study participants for their commitment in responding to our questionnaires.

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The authors declare that they have no competing interests.

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Ethical clearance was obtained from the Ethical Review Committee of Bahir Dar University, College of Medicine & Health Sciences, and School of Nursing. The objective and purpose of the study were explained to officials at the Woreda and Kebele (smallest governmental administrative division) and a written permission consent was obtained from the study participants. For those study participants whose age is below 18 years consent to participate in the study was obtained from their parent during the data collection time.

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Department of Nursing, College of Medicine & Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

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Semachew Kasa, A., Tarekegn, M. & Embiale, N. Knowledge, attitude and practice towards family planning among reproductive age women in a resource limited settings of Northwest Ethiopia. BMC Res Notes 11 , 577 (2018). https://doi.org/10.1186/s13104-018-3689-7

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Determinants of the Use of Family Planning Methods in Ethiopia Using a Multilevel Approach

Sisay Yohannes Gagabo

Department of Statistics, Bonga University, Bonga, Ethiopia

Kenenisa Abdisa Kuse

Department of Statistics, Bule Hora University, Bule Hora, Ethiopia

Add to Mendeley

Family planning is the most effective method to control the continuing growth of the population. Ethiopia is currently one of the fastest growing countries in the world, with a growth rate of 3.02% per year. In the next forty to fifty years, Ethiopia is predicted to account for a significant portion of the population growth expected throughout Africa. According to Ethiopia Mini Demographic and Health Survey (EMDHS) 2019, the intended use of family planning is only 36% in the country. Therefore, this study aimed to assessing the socio-demographic determinants of use of family planning among the community and regions in Ethiopia. A total of five thousand four hundred forty-three women in the age group 15 to 49 years were considered in the final data analysis. Descriptive statistics, chi-square test of independency and multilevel random coefficient model were used in the study. Sixty-four percent of the eligible women who were included in the study did not use family planning. The outcome also shows that regional and community differences accounted for almost 20% (18.6) and 22.2% (14.1) of the variation in family planning use, respectively. Women’s preceding birth interval, residence (rural/urban), their educational level, number of living children, wealth status, educational level of their husbands, currently wanted pregnancy, sex of household head, their employment status, regions and exposure to mass media have been identified as an important determinant of intended use of family planning among women of Ethiopia. To address identified concerns and assure improved levels of family planning use, decisive action is needed. This action may include educational intervention, ongoing monitoring and evaluation of family planning services, and scheduling training for providers. This information is crucial for developing strategic policies and raising the standard of family planning services. This research is crucial for developing strategic policies and raising the standard of family planning services. To ensure the success of the national family planning initiatives, the government and relevant organizations must put plans into place that target these effects.

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Family Planning Methods, Multilevel Analysis, EMDHS, 2019

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[5]	A. Sonfield, K. Hasstedt, and R. B. Gold, “Moving forward: family planning in the era of health reform,” 2014.
[6]	U. Nations, “Family planning and the 2030 agenda for sustainable development,” Dep Econ Soc Aff Popul Div [Internet], 2019.
[7]	V. Kantorová, M. C. Wheldon, P. Ueffing, and A. N. Z. Dasgupta, “Estimating progress towards meeting women’s contraceptive needs in 185 countries: A Bayesian hierarchical modelling study,” PLoS Med., vol. 17, no. 2, p. e1003026, 2020.
[8]	J. J. Frost, L. B. Finer, and A. Tapales, “The impact of publicly funded family planning clinic services on unintended pregnancies and government cost savings,” J. Health Care Poor Underserved, vol. 19, no. 3, pp. 778–796, 2008.
[9]	I. C. F. CSA, “Ethiopia demographic and health survey: key indicators report,” Cent. Stat. Agency, Addis Ababa, Ethiop., 2016.
[10]	A. Agresti and Y. Min, “On sample size guidelines for teaching inference about the binomial parameter in introductory statistics,” Dep. Stat. Univ. Florida. Gainesville, Florida, vol. 32611, p. 38545, 2002.
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[12]	H. K. Kasaye, F. T. Bobo, M. T. Yilma, and M. Woldie, “Poor nutrition for under-five children from poor households in Ethiopia: Evidence from 2016 Demographic and Health Survey,” PLoS One, vol. 14, no. 12, p. e0225996, 2019.
[13]	H. Goldstein, “Multilevel statistical models: John Wiley & Sons,” Chichester, UK, 2011.
[14]	Z. Öztürk and M. A. Cengiz, “Comparisons of markov chain monte carlo convergence diagnostic tests for bayesian logistic random effect models,” 2016.
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[16]	A. Shumye, W. Girma, and A. R. Muralidharan, “A STATISTICAL ANALYSIS OF FAMILY PLANNING PRACTICES IN ETHIOPIA: AN APPLICATION OF MULTINOMIAL REGRESSION,” Eur. J. Mol. Clin. Med., vol. 7, no. 11, pp. 1458–1475, 2020.
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[18]	M. Kassim and F. Ndumbaro, “Factors affecting family planning literacy among women of childbearing age in the rural Lake zone, Tanzania,” BMC Public Health, vol. 22, no. 1, p. 646, 2022.
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Gagabo, S. Y., Kuse, K. A. (2024). Determinants of the Use of Family Planning Methods in Ethiopia Using a Multilevel Approach. International Journal of Science, Technology and Society , 12 (1), 35-43. https://doi.org/10.11648/j.ijsts.20241201.14

Gagabo, S. Y.; Kuse, K. A. Determinants of the Use of Family Planning Methods in Ethiopia Using a Multilevel Approach. Int. J. Sci. Technol. Soc. 2024 , 12 (1), 35-43. doi: 10.11648/j.ijsts.20241201.14

Gagabo SY, Kuse KA. Determinants of the Use of Family Planning Methods in Ethiopia Using a Multilevel Approach. Int J Sci Technol Soc . 2024;12(1):35-43. doi: 10.11648/j.ijsts.20241201.14

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PMC10490906

Utilization of family planning and associated factors among women with disabilities in ethiopia: A systematic review and meta-analysis

Tesfanesh lemma demisse.

1 Department of Midwifery, Asrat Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia

Mulualem Silesh

Birhan tsegaw taye, tebabere moltot, moges sisay chekole, maritu ayalew.

2 Department of Midwifery, Teda Health Science College, Gondar, Ethiopia

Associated Data

All relevant data are within the manuscript and its Supporting Information files.

Persons with disabilities have a right to make their own choices about their bodies, health, and lives, especially regarding their sexual and reproductive health. But they may experience more challenges than women without disabilities in having their reproductive health needs met. So there is an urgent need to scale up disability inclusion in all levels of the health system including family planning. Therefore, the objective of this study was to estimate the pooled prevalence of Family Planning Utilization and Associated Factors among Women with Disabilities in Ethiopia.

Methodology

Studies were gathered from Pub Med/MEDLINE (681), Google Scholar (426), African Journal of Online (AJOL) (36), CINAHL (211), HINARI (191), Scopus (86), Science Direct (62), Excerpta Medica database (EMBA, SE) (113), DOAJ (38), Web of Science (26), Google (271), and other organization’s websites (2) using a combination of search terms and Boolean operators. The modified Newcastle Ottawa Scale (NOS) for cross-sectional research was used by three authors to independently assess the quality of each study. For statistical analysis, STATATM Version 11 software was employed. For the meta-analysis, the random-effects (Der Simonian and Laird) technique was applied. The heterogeneity test was performed using I-squared (I 2 ) statistics. A one-out sensitivity analysis was performed.

A total of 7 articles with 2787 participants were included in this systematic review and meta-analysis. The pooled prevalence of family planning utilization among Women with Disabilities was 29.6% (95% CI: 22.3, 36.8); I2 = 94.6%). Women who were in marital union (p<0.001) and who had a discussion with their husbands (p = 0.007) were factors significantly associated with the utilization of family planning among women with disabilities.

The finding of this study showed that utilization of family planning among women with disability is relatively lower than the Ethiopian Demographic Health Survey 2019. Therefore, the discussions with the partner and their engagement in decisions to use family planning are critical to increase its use.

1. Introduction

A disability is defined as a condition or function judged to be significantly impaired relative to the usual standard of an individual or group. The term is used to refer to individual functioning, including physical impairment, sensory impairment, cognitive impairment, intellectual impairment mental illness, and various types of chronic disease [ 1 ]. According to the 2021 World Health Organization (WHO) report, Over 1 billion people in the world live with some form of disability [ 2 ]. Women account for the majority of the disabled population in the world; globally, one in five women lives with a disability compared to one in eight men. In low and middle-income countries, women are estimated to comprise up to three-quarters of persons with disabilities [ 3 ].

Family planning is "the ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births [ 4 ]. It is the information, means, and methods that allow individuals to decide if and when to have children [ 5 ]. Access to safe, voluntary family planning is a human right and is critical in ensuring gender equality and women’s empowerment, and it is a key factor in reducing poverty and improving livelihoods [ 5 – 7 ]. Persons with disabilities have a right to make their own choices about their bodies, health, and lives, especially regarding their sexual and reproductive health and rights and freedom from discrimination and violence [ 8 ]. They have the same sexual and reproductive health needs and rights as people without disabilities, but often they are not given information about reproductive and sexual health or adequate care [ 9 , 10 ].

Studies indicate that disabled women were at higher risk of experiencing sexual violence than nondisabled women [ 11 – 13 ], and experience more challenges than women without disabilities in having their reproductive health needs met. Women with Disabilities (WWDs) face multiple barriers to quality contraceptive care [ 14 ], whether through stigma, increased risk of violence or abuse, lack of access to care [ 15 ], prejudices, and discrimination from healthcare service providers [ 14 , 16 ]and receive poor quality services [ 2 , 17 ].

So there is an urgent need to scale up disability inclusion in all levels of the health system, particularly primary health care [ 2 ] like family planning [ 15 ]. According to a review conducted in Low-and Middle-Income countries, contraception use among WWDs ranged from 13% to 31.1%, with 24.3 percent of unmet needs [ 18 ]. This study aimed to determine the pooled prevalence and associated factors for FP service utilization among WWDs in Ethiopia.

2. Methods and materials

2.1.study design and search strategy.

The purpose of this systematic review and meta-analysis was to assess the pooled prevalence of family planning utilization and associated factors among women with disabilities in Ethiopia using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement guidelines [ 19 , 20 ]. We searched the PROSPERO database to see whether there were any comparable on-going systematic reviews and meta-analyses.

Three authors searched the following databases for relevant studies: From Pub Med/MEDLINE (681), Google Scholar (426), African Journal of Online (AJOL) (36), CINAHL (211),HINARI (191),Scopus (86), Science Direct (62),Excerpta Medica database (EMBA, SE) (113), DOAJ (38),Web of Science (26),Google (271), and other organization’s websites (2) by using the full title (Utilization of family planning and associated factors among women with disability in Ethiopia) and using the following searching keywords or terms; ’’Family planning utilization’’, ’’use of family planning methods, ’’utilization of family planning services’’, ’’State of family planning’’, ’’Family Planning Service Utilization’’, ’’practice of family planning’’, ’’Providing family planning services’’, ’’Contraceptive utilization’’, ’’Influencing Factors’’, ’’associated factors’’, ’’ factors influencing’’, ’’Disabled women, ’’disables’’, ’’Women with disability’’, ’’disability’’, ’’disabilities’’ and, ’’Ethiopia" In order to find any further missed studies, the reference lists of all included published and unpublished studies were reviewed. All fields and MeSH (Medical Subject Headings) terms with Boolean operators ("OR" and/or "AND") were used to search studies in the advanced PubMed search engine ( S1 File ).

2.2.Eligibility criteria

Both published and unpublished observational studies in English that report the prevalence and/or associated factors of family planning utilization among disabled women in Ethiopia were included [ 21 – 27 ]. This review also included studies done up until November 15, 2022. Studies with a different operational definition or outcome of interest, as well as those whose full texts were unavailable, were excluded [ 28 – 32 ].

2.3.Outcome measurement, study selection, and quality assessment

Family planning utilization was considered when the women with disability had ever used any modern method of contraceptive during her sexual life and/or she is current user [ 23 , 26 , 27 ]. After studies were searched from different international databases and organization websites, studies were screened by using the following criteria (duplication, relevancy, accessibility of full text, and outcomes of interest). Finally, the quality of each study was assessed using the standard quality assessment tool [Newcastle-Ottawa Scale (NOS)] [ 33 ] and was assessed by five authors (TL, BTT, TM, MSC, and MA) independently using the following components: selection, comparability, and outcome; which were graded by five stars, two stars, and three stars respectively. Any disagreements between the five authors during quality appraisal were resolved by another author (MS) through discussion and re-evaluation of selected studies. For analysis, only the primary studies with a medium score (fulfilling 50% of the quality evaluation criteria) and above were included [ 34 ] ( S2 File ).

Operational definition

Women with disability : - women having hearing, visual and physical impairments or limb defects [ 23 , 27 ].

Family planning utilization : - The women with disability had ever used any modern method of contraceptive during her sexual life and or she is current user [ 23 , 26 , 27 ].

Total fertility rate (TFR) : - is the measure of children a women would have over her life time if she were to follow current age-specific fertility rates [ 26 ].

Data extraction process

Three independent authors (TL, MS, and BTT) extracted the data using a data extraction format prepared in a Microsoft Excel 2010 spreadsheet. The following information was extracted: the first author’s name, the year of study, the study area, the Region, the study design, the sample size, the sampling method, the prevalence of family planning, and the associated factors with their odds ratios. Differences during data extraction were resolved through discussion and consensus by involving the fourth author (TM).

Data synthesis and statistical analysis

For analysis, STATA Version 11 software was used. Because high heterogeneity across studies was identified using inverse variance ( I 2 ) statistics with its corresponding p-value ( I 2 = 94.6%, p < 0.001) [ 35 – 37 ], a random effects model was applied to determine the pooled prevalence of family planning utilization. Meta-regression and subgroup analysis were also used to identify the source of heterogeneity across studies by using year of study, and region. To check for publication bias, a funnel plot and Egger’s test were used [ 38 ]. The statistical significance of publication bias was determined using a p-value less than 0.05 [ 39 ]. Texts, tables, and forest plots with effect and 95% CI measures were used to present the results.

3.1.Study selection

Using various search strategies, a total of 2080 studies were retrieved from various international databases and Ethiopian university institutional repositories. All retrieved studies were screened using the Endnote 7 reference manager, and 1421 were removed due to duplication. Then, 652 studies were eliminated due to unrelated titles, abstracts, inaccessibility of full text, and differences in outcomes of interest. Finally, for the meta-analysis, seven studies that met the inclusion criteria were considered ( Fig 1 ).

An external file that holds a picture, illustration, etc.
Object name is pone.0291189.g001.jpg

3.2.Characteristics of included studies

This systematic review and meta-analysis included seven primary studies. All of the studies included were cross-sectional, with sample sizes ranging from 162–701 [ 25 , 26 ]. Regarding the study’s region, three articles were from the Amhara region [ 22 , 23 , 26 ], two from Addis Ababa [ 24 , 25 ], one from SNNP [ 21 ] and one from the Tigray [ 27 ] region with years of study ranging from 2013 to 2020. The highest prevalence of family planning utilization was reported by Abera S. (44.4%) [ 25 ], which was done in the Addis Ababa, while the lowest utilization was reported in the Amhara region by Beyene GA, et al. (15.8%) (23) ( Table 1 ).

Authors Name	Publication Year	Study setting	Region	Study design	sample	prevalence% (95% CI)
Yesgat YM, et al.	2019	Arba Minch	SNNPR	Cross Sectional	398	33.7 (29.06, 38.34)
Mekonnen AG, et al.	2019	Debre Berhan	Amhara	Cross Sectional	397	24.5 (20.27, 28.73)
Beyene GA, et al.	2013	Gondar	Amhara	Cross Sectional	267	15.8 (11.42, 20.18)
Yimer AS, et al.	2017	Addis Ababa	Addis Ababa	Cross Sectional	326	31.1 (26.07, 36.13)
Abera S (upulished)	2016	Addis Ababa	Addis Ababa	Cross Sectional	701	44.4 (40.72, 48.08)
Tilahun A (upulished)	2020	Bahir Dar	Amhara	Cross Sectional	162	30.2 (23.13, 37.27)
Tsegay K, et al.	2013	Mekelle	Tigray	Cross Sectional	536	27.2 (23.43, 30.97)

3.3.Prevalence of family planning utilization among women with disability

A total of 7 (five published and two unpublished) studies with 2787 women were included in this systematic review and meta-analysis to estimate the pooled prevalence of family planning utilization among women with disabilities in Ethiopia. Accordingly, the overall estimated pooled prevalence of family planning utilization among women with disabilities with a random effects model was 29.57% (95% CI: 22.30, 36.83) with a heterogeneity index (I 2 ) of 94.6% (p = 0.000) ( Fig 2 ).

An external file that holds a picture, illustration, etc.
Object name is pone.0291189.g002.jpg

3.4.Publication bias and Heterogeneity

To check for publication bias, a funnel plot and Egger’s test [ 37 ] were used. The statistical significance of publication bias was determined using a p-value less than 0.05 [ 38 ]. Accordingly, the funnel plot results revealed a symmetrical pattern, indicating that the included studies do not have a publishing bias ( Fig 3 ). Furthermore, Egger’s regression test is not significant, indicating that there was no publication bias in the studies ( Table 2 ).

An external file that holds a picture, illustration, etc.
Object name is pone.0291189.g003.jpg

Std.Eff	Coef.	Std. Err.	T	p> t	[95% Conf. Interval]
Slope	3.587349	0.7756355	4.63	0.006	1.593514,5.581183
Bias	-0.1038034	0.3440247	-0.30	0.775	-0.988147,0.7805403

3.5.Subgroup analysis and sensitivity analysis

Significant heterogeneity was observed among included primary studies. To identify the source of heterogeneity, sub-group analysis was performed based on the region and year of study. As a result, the overall prevalence of family planning utilization was found to be high in Addis Ababa region studies [32.61, (26.39, 38.82)] ( Fig 4A ) and studies conducted after 2015 [32.61, (26.39, 38.82)] ( Fig 4B ).

An external file that holds a picture, illustration, etc.
Object name is pone.0291189.g004.jpg

A. Subgroup analysis based on the region among women with disability in Ethiopia. B. Subgroup analysis based on year of study among women with disability in Ethiopia.

A leave-one-out sensitivity analysis was done to check the effect of individual studies on the pooled estimate of family planning utilization. The result indicated removing a single study did not have a significant influence on pooled prevalence and the pooled prevalence of family planning utilization was observed low at 25.63% (3.93, 167.08%) and high at 31.78% (5.22, 193.66%) when Abera S. and Beyene GA, et al. were omitted respectively ( Table 3 ).

Study omitted	Year of study	Pooled estimate (%)	95%CI
Yesgat YM, et al.	2019	28.03	4.68,167.89
Mekonnen AG, et al.	2019	29.56	4.8, 182.05
Beyene GA, et al.	2013	31.79	5.22, 193.66
Yimer AS, et al.	2017	28.42	4.82, 167.02
Abera S (upulished)	2016	25.63	3.93, 167.08
Tilahun A (upulished)	2020	28.62	5.13, 159.65
Tsegay K, et al.	2013	29.09	4.51, 187.48

3.6.Factors associated with family planning utilization among women with disability

Nine variables (age, marital status, discussion with partner, kowledge on FP methods, presence of FP providing nearby health facility, women’s educational status, economic status, decision maker to use FP methods, and health facility keep the confidentiality & privacy) were extracted to identify factors associated with family planning utilization among women with disability. Of this marital status, discussion with a partner marital status, kowledge on FP methods, presence of FP providing nearby health facility, economic status, decision maker to use FP methods, and health facility keep the confidentiality & privacy were found to be significantly associated with family planning utilization among WWDs ( Table 4 ). However, there was no statistically significant association between women’s age, educational status and FP utilization.

Determinants	Comparisons	Number of studies	Sample size	OR(95% CI)	P- value	I (%)	Heterogeneity test (P- value)
Marital Status	married Vs. unmarried	3	1662	11.15 (4.82‒11.98)	0.003	66.2	<0.001
Age	<25 Vs. ≥ 25	2	593	3.21 (1.01‒10.18)	<0.001	93.8	0.021
Discussion with partner	Yes Vs. No	2	649	2.49 (1.76‒3.51)	0.301	6.5	0.012
Kowledge o FP methods	Good Vs. Poor	2	735	1.77 (1.22–2.56)	0.003	0	0.383
Presence of FP providing nearby Health facility	Yes Vs. No	2	698	1.49 (0.03–69.71)	0.837	96.9	<0.001
Educational Status	Illiterate Vs. Literate	1	267	1.81 (0.92–3.59)	0.088	0	<0.001
Economic status	Poor Vs. Rich	1	267	6.66 (2.94–15.05)	<0.001	0	-
Decision maker to use family planning	Husband Vs. Women	1	162	0.08 (0.03–0.21)	<0.001	0	-
Health Workers keep the confidentiality & privacy	Yes Vs. No	1	536	5.14 (3.13–8.43)	<0.001	100	-

*Significant level <0.05.

The pooled effect of the marital status on FP utilization among women with disabilities was evaluated by using three primary studies (21,24,27) The result of this study revealed that marital status was significantly associated with FP utilization and the likelihood of utilizing FP was 8.6 times higher among those women who had in marital union than their counterparts [OR: 8.63; 95% CI (3.17, 23.46); P<0.001], with heterogeneity (I 2 = 91.5%, p-value <0.001) ( Fig 5 ).

An external file that holds a picture, illustration, etc.
Object name is pone.0291189.g005.jpg

To determine the pooled effects of women’s discussions with their partners on FP utilization, two studies were included [ 25 , 26 ]. The findings revealed that women’s discussion with their partners was significantly associated with the use of FP; those who discussed with their partner were 6 times more likely to use FP than those who did not [OR: 6.08; 95% CI (1.64, 22.53); P = 0.007] with heterogeneity (I 2 = 84.2%, p-value = 0.012) ( Fig 6 ).

An external file that holds a picture, illustration, etc.
Object name is pone.0291189.g006.jpg

A total of two primary studies [ 21 , 22 ] were included to assess the association between knowledge on FP and utilization of FP among women with disabilities. Accordingly, women who had good knowledge were 1. 77 times more likely to utilize FP than those who had poor kowledge [OR = 1. 77, 95% CI = (1.22, 2.56); P = 0.003] with a mild type of heterogeneity between two variables (I 2 = 0.0%, p value = 0.383) ( Fig 7 ) .

An external file that holds a picture, illustration, etc.
Object name is pone.0291189.g007.jpg

The finding of this study revealed that the economic status were significantly associated with FP utilization among women with disabilities [ 23 ] and the likelihood of utilizing FP service were 6.66 times higher in those mothers who had rich economic status [OR = 6.66, 95% (CI = 2.94,15.05); P <0.001] with heterogeneity index of (I 2 = 0.0%).This finding also revealed that decision maker to use family planning was significantly associated with the use of FP [ 26 ]; Disabled women whose decision to use family planning was made by their husband were 92% less likely to utilize family planning methods than women who made decisions by themselves [OR: 0.08; 95% CI (0.03, 0.21) P<0.001] with heterogeneity index (I 2 = 0%) ( Table 4 ) .

Furthermore, the pooled effects of participants who trusted health workers as capable to keep their privacy were significantly associated with the utilization of family planning [ 27 ]. Accordingly, participants who trusted health workers as capable to keep their privacy was 5.14 (3.13–8.43) times more likely to utilize family planning methods [OR = 3.73; 95% CI (3.13, 8.43) P<0.001] with heterogeneity index of 100% ( Table 4 ).

4. Discussion

The purpose of this systematic review and meta-analysis was to determine the pooled prevalence and associated factors of FP utilization among Ethiopian women with disabilities. To the best of our knowledge, this meta-analysis is the first of its kind in determining the national prevalence and significant factors of FP utilization among WWDs in Ethiopia, which will be used as input for policymakers, health care providers, and other stakeholders in developing evidence-based strategies to improve FP utilization among WWDs.

The overall pooled prevalence of family planning utilization among women with disabilities in Ethiopia was 29.57% (95% CI: 22.30, 36.83), which is lower than the Ethiopian Demographic and Health Survey (EDHS) report 2019 [ 40 ]. This could be because the EDHS reports family planning utilization among all women, but this review was limited to WWDs. Also, it is lower than a review conducted in Ethiopia [ 41 , 42 ]. The difference might be due to the difference in the study period of primary studies and the study population, since the two studies are conducted among adolescents and postpartum women who are more information about sexual and reproductive health from different sources.

However the result of this review was higher than the minimum rate of family planning utilization among WWDs, according to a review conducted by Horner-Johnson [ 43 ] and Beyene GA [ 18 ]. The result of this study could be a pooled estimate of different studies, whereas Horner-Johnson and Beyene GA report the minimum and maximum range of family planning utilisation among WWDs by reviewing literature from different settings, and the comparison in this study was based on the minimum rage from the report. In addition, it was higher than a review conducted by Y.F. Geda and T.M. Berhe [ 44 ]. The difference could be due to differences in study participants and contraceptive type, as this study was conducted among WWDs for the use of all types of contraceptives, whereas a study by Y.F. Geda and T.M. Berhe was conducted among postpartum women for the use of immediate postpartum intrauterine contraceptive devices (IUCD).

Based on the subgroup analysis result, the prevalence of family planning utilization was found to be high in Addis Ababa region studies [32.61, (26.39, 38.82)]. This could be attributed to the city’s urbanization and women’s increased awareness. Because Addis Ababa is the country’s capital, disabled women may have more access to information on family planning. In Addis Ababa, there is also the Ethiopian Women with Disability Association, where many women participate and discuss their health, including family planning.

In addition, this review revealed that there is a high prevalence of family planning utilization among studies conducted after 2015 [32.61, (26.39, 38.82)]. The reason could be that after the Millennium Development Goals (MDG) were completed in 2015; The Ethiopian government developed a new plan called the Costed Implementation Plan for Family Planning, which includes various strategies to increase the contraceptive prevalence rate and decrease total fertility rate by 2020, that may encourage more women to use contraception [ 45 ]. Furthermore, various information distribution technologies such as social media are increasingly being used to disseminate information regarding family planning options. This may make it easier for women to learn about the advantages of family planning, where to get it, and how to use it.

In this review, the odds of utilizing FP were 8.6 times higher among women who had been in a marital union than their counterparts. This is in line with a review conducted in sub-Saharan Africa [ 46 ], Ethiopia [ 47 ] and a report from USAID [ 48 ]. This is because family planning can increase partners’ involvement in decisions about whether and when to have children while also assisting them in avoiding unintended pregnancy. It also provides her with enough time and opportunity to love and care for her husband and children. As a result, partner involvement in family planning decisions is critical, and a married woman may be encouraged to use contraception by her partner.

The findings of this study also revealed that women who discussed with their partner were 6 times more likely to use FP than those who did not. This is consistent with the review conducted in Sub-Saharan Africa [ 46 , 49 ]. This may be due to the fact that couples who talk about FP issues are more likely to jointly decide on the type of contraceptive method to use, the number of children to have, and the spacing between the children. As a result, they are more likely to use the service. Also Male participation in contraceptive use increases women’s uptake, according to a report from a review protocol by Anbesu and his colleagues [ 50 ]. In addition male involvement plays a role in the use of reproductive and maternal health services, and any factor that influences the partner’s attitude towards these services will have an effect on women’s use, either positively or negatively. So talking with a partner may give them the impression that she values their influence in her life, giving the woman more freedom to make decisions.

This study found that disabled women who had good knowledge were significantly associated with utilization of family planning. This finding was supported by a review finding from Ethiopia [ 42 , 44 ] and around the globe [ 49 ]. This might be attributed to an in-depth knowledge of family planning methods, which can improve women’s understanding and awareness of the importance and side effects of various contraceptive methods, allowing them to make an informed decision on the method to be used and, as a result, increase their usage of this service.

In this meta-analysis, economic status of the women was positively associated with FP utilization. Women who had rich economic status were more likely to utilize FP compared to their counterparts. This is consistent with a studies conducted by Mekonnen AG et.al [ 42 ]. This could be because women with higher economic status are more likely to be exposed to information on family planning due to their health seeking behavior for various reasons and their use of various information-gathering mass media such as the internet. The information may have influenced their use by helping them comprehend the purpose and importance of family planning methods.

In addition these reviews showed that a woman’s whose decision to use family planning was made by their husband were less likely to utilize family planning methods than women who made decisions by themselves. This finding was consistent with a study finding from different settings [ 51 , 52 ]. This might be due to the fact that decision-making autonomy on contraceptive use influences their utilization. Women’s independent decisions on reproductive health issues like FP are crucial and increase women’s access to health information and utilization. So less autonomy in the decision regarding contraceptive use due to male dominance at the household level may affect their utilization.

Accordingly, this review revealed that participants who trusted health workers as capable to keep their privacy was more likely to utilize family planning which is supported by a review conducted by Brittain et al. [ 53 ]. A possible explanation is that maintaining confidentiality and ensuring privacy are crucial for effective, sensitive management of potentially stigmatizing health conditions and improved quality care, including getting sexual and reproductive health services [ 54 , 55 ] So, if the woman believes the health care practitioner will respect her privacy and confidentiality, she is more likely to use the service.

There are limitations to this study. The absence of studies from some Ethiopian regions in this study makes it challenging to extrapolate the results to the national level. Second, the results should be interpreted cautiously due to the significant heterogeneity among the studies. Moreover, only observational study articles published in English were considered. Finally, we found it challenging to compare our results because there were few systematic reviews and meta-analyses conducted at the national, regional, and international levels.

5. Conclusion

According to the findings of this study, only one-third of disabled women in Ethiopia utilize family planning. Being married and discussing with a partner were significantly associated with family planning utilization among WWDs. Therefore, the discussions with the partner and their engagement in decisions to use family planning are critical to increase its use. It also important to increase access to quality contraceptive care and improve negative clinician attitudes and awareness of disabled women to increase utilization. In addition, it is critical to pay more attention to the reproductive health care needs of women with disabilities to improve health care equity.

Supporting information

S1 checklist, abbreviations.

CI	Confidence Interval
EDHS	Ethiopian Demographic and Health Survey
FP	Family Planning
MDG	Millennium Development Goals
SNNPR	Southern Nations, Nationalities and Peoples Region
WHO	World Health Organization
WWDs	Women with Disabilities
USAID	U.S. Agency for International Developmen

Funding Statement

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Data Availability

PLoS One. 2023; 18(9): e0291189.

Decision Letter 0

16 May 2023

PONE-D-22-35356Utilization of Family Planning and Associated Factors among Women with Disabilities in Ethiopia: a systematic review and meta-analysisPLOS ONE

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- You said the PROSPERO registration is ongoing, what is the importance of registering it after you have published the review?

- It is better of specify the number of articles you have gotten from each data bases (Pub Med/MEDLINE=? Google Scholar=? African Journal of Online (AJOL)=? CINAHL=?, HINARI=?, Scopus=?, Science

Direct, Excerpta Medica database (EMBA, SE), DOAJ, Web of Science, Google, and other organization's websites=?)

- What is the final mesh term used in each searching engines?

- Is publication year or study period better indicating the time period of the articles?

- What does it mean p = 0.000?

- you have checked three independent variables to assess their association with the outcome variable, some single articles revealed more than three significant variables?

- the discussion is shallow, it needs to entertain more perspectives

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Reviewer #1: the matanalysis is very impotant as diasbilitis is a topic very poorly reported in current literture. this study underlines in ethiopoiaa those aspects in women with disabilities encoiunterin pregancy

Reviewer #2: Review Report

Title: Utilization of Family Planning and Associated Factors among Women with Disabilities in Ethiopia: a systematic review and meta-analysis.

Manuscript Number: PONE-D-22-35356.

a. Acknowledge for addressing disadvantaged segment of the community.

b. Scope: The scope of the issue and the outcome variables needs re-operationalization. The authors failed to include fertility.

c. Methods: Whether retracted articles are used in the analysis were not mentioned,

d. Illegibility: Not included all observational studies.

e. Whether all studies defined disability in the similar way: Not explained.

f. Data analysis and Presentation: Inadequate.

g. Authorship: inconsistent in the main document and in the methods section.

h. Language and statistic: Need major revision.

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Reviewer #1: Yes: Erich Cosmi

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Author response to Decision Letter 0

23 Jun 2023

The authors would like to thank the editorial team and team of reviewers for constructive and valuable comments. The authors are very happy to submit the revised version of the manuscript entitled “Utilization of Family Planning and Associated Factors among Women with Disabilities in Ethiopia: a systematic review and meta-analysis” for its publication in your Journal. The comments of the editors and the reviewers were highly insightful and enabled us to greatly improve the quality of our manuscript. In this revised manuscript we made substantial changes to address your concerns in a point-by-point response. We are very keen to incorporate further comments, if any, for the betterment of the final manuscript.

Response to the Editor

1. You said the PROSPERO registration is on-going, what is the importance of registering it after you have published the review?

Answer –Thank you for your comment; sorry for the inconvenience, and it is corrected in the revised manuscript.

2. It is better of specify the number of articles you have gotten from each data bases (Pub Med/MEDLINE=? Google Scholar=? African Journal of Online (AJOL)=? CINAHL=?, HINARI=?, Scopus=?,Science Direct, Excerpta Medica database (EMBA, SE), DOAJ, Web of Science, Google, and other organization's websites=?)

Answer – Thank you for your question. Here are the number of articles from each data base Pub Med/MEDLINE=681 Google Scholar=426 African Journal of Online (AJOL) =36 CINAHL=211, HINARI=191, Scopus=86, Science Direct=62, Excerpta Medica database (EMBA, SE) = 113, DOAJ= 38, Web of Science=26, Google= 271 and organization's websites=2)

3. What is the final mesh term used in each searching engines?

Answer –Thank you for your questions; you can see additional file 1 to understand the whole search engine by one of the most usable data base PubMed.

Here are some of the mesh terms that are used in searching engines.

Word Mesh terms

Utilization of Family Planning Family planning utilization, use of family planning methods, utilization of family planning services, State of family planning, Family Planning Service Utilization, practice of family planning, Providing family planning services, Contraceptive utilization

Factors associated with family planning Influencing Factors, associated factors, factors, factors influencing,

Women with disabilities Disabled women, disables , Women with disability, disability, disabilities,

4. Is publication year or study period better indicating the time period of the articles?

Answer –Thank you for your questions; the study period is better indicating the time period of the articles and publication year also used to determine how old the information can be.

1. What does it mean p = 0.000?

Answer –Thank you for your comment; it is an editorial problem and corrected in the revised manuscript

2. You have checked three independent variables to assess their association with the outcome variable, some single articles revealed more than three significant variable.

Answer – Thank you for your inquiry; you are right that some single articles revealed more than three significant variable. But the only factor identified as a significant factor in the two and above primary studies was included in this review and meta-analysis. That is the reason for only three independent variables were assessed for their association.

3. The discussion is shallow, it needs to entertain more perspectives

Answer –Thank you for your comment; it is accepted and corrected in the revised manuscript.

Response to the reviewer

Reviewer #1: the Meta analysis is very important as a disability is a topic very poorly reported in current literature. This study underlines in Ethiopia those aspects in women with disabilities encountering pregnancy.

Answer –Thank you for your insightful idea.

Reviewer #2:

A. Acknowledge for addressing disadvantaged segment of the community.

Answer –Thank you for your idea.

B. Scope: The scope of the issue and the outcome variables needs re-operationalization. The authors failed to include fertility.

Answer – Thank you for your comment; it is accepted and corrected on page 5 line 22-28 of the revised manuscript.

C. Methods: Whether retracted articles are used in the analysis were not mentioned,

Answer – Thank you for your comment; as mentioned in the Prisma diagram(figure 1), 13 articles were retracted to assess their eligibility, but only seven studies were included in the analysis and the other six articles were excluded because of the outcome of interest is not reported. It is also described on page 6, line 19-24 of the revised manuscript.

D. Illegibility: Not included all observational studies.

Answer – Thank you for your inquiry; First the authors plan to include all observational studies but all studies who fulfil the eligibility criteria in this review were crossectional, that’s why the authors don’t included all observational studies.

E. Whether all studies defined disability in the similar way: Not explained

Answer – Thank you for your suggestion, majority of the studies included in this review defined people with disability as women having hearing, visual and physical impairments or limb defects (1–5). This is described in the revised manuscript on page 5, line 23-24.

F. Data analysis and Presentation: Inadequate.

Answer – Thank you for your comment. The authors carried out all of the necessary analysis to show the findings of the meta-analysis, such as a random effects model that was used to determine the pooled prevalence of family planning utilisation, as shown in Figure 2. Because there is heterogeneity across studies, meta-regression and subgroup analysis were used to identify the source of heterogeneity using the sample size, year of study, and region, as shown in Figures 4A and 4B. A funnel plot and Egger's test were used to check for publication bias, as shown in Figure 3 and Table 2. A leave-one-out sensitivity analysis was also performed to see how individual studies affected the pooled estimate of family planning utilisation. The results showed that removing a single study had no significant effect on pooled prevalence, as shown in Table 3.

G. Authorship: inconsistent in the main document and in the methods section.

Answer – Thank you for your comment; it is accepted and corrected in the revised manuscript.

H. Language and statistic: Need major revision.

Answer – Thank you for your feedback; it has been accepted, and the paper has been revised by language experts and online writing tools like Grammarly and QuillBot. As previously stated, this study performed all of the necessary analysis in order to show the results of the meta-analysis.

1. Beyene GA, Munea AM, Fekadu GA. Modern contraceptive use and associated factors among women with disabilities in gondar city, amhara region, north west ethiopia: A cross sectional study. Afr J Reprod Health. 2019;23(2):101–9.

2. Kellali T, Hadush G FH. Modern Contraceptive Methods Utilization and Associated Factors among Women with Disabilities. Int J Pharm Biol Sci Fundam [Internet]. 2017;13(01)(01):1–8. Available from: www.ijpbsf.com

3. Mekonnen AG, Bayleyegn AD, Aynalem YA, Adane TD, Muluneh MA, Asefa M. Level of knowledge, attitude, and practice of family planning and associated factors among disabled persons, north-shewa zone, Amhara regional state, Ethiopia. Contracept Reprod Med. 2020;5(1):1–7.

4. Mesfin Yesgat Y, Gebremeskel F, Estifanous W, Gizachew Y, Jemal S, Atnafu N, et al.

Utilization of Family Planning Methods and Associated Factors Among Reproductive-Age Women with Disability in Arba Minch Town, Southern Ethiopia

. Open Access J Contracept. 2020;Volume 11:25–32.

5. Abera S. The Assessment of Determinants of family planning use and unmet need among women of reproductive age group with disabilities in Addis Ababa. 2016;(November).

Submitted filename: Response to Reviewers.docx

Decision Letter 1

28 Jun 2023

PONE-D-22-35356R1Utilization of Family Planning and Associated Factors among Women with Disabilities in Ethiopia: a systematic review and meta-analysisPLOS ONE

Dear Dr. Lemma,

I have attached the comments.

Please submit your revised manuscript by Aug 12 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at gro.solp@enosolp . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Lebeza Alemu Tenaw

Academic Editor

Additional Editor Comments :

I have attached the additional comments that should be considered in the next revision.

Submitted filename: Manuscript-C.docx

Author response to Decision Letter 1

17 Jul 2023

The authors would like to thank the editorial team for constructive and valuable comments. The authors are very happy to submit the revised version of the manuscript entitled “Utilization of Family Planning and Associated Factors among Women with Disabilities in Ethiopia: a systematic review and meta-analysis” for its publication in your Journal. The comments were highly insightful and enabled us to greatly improve the quality of our manuscript. In this revised manuscript we made substantial changes to address your concerns in a point-by-point response. We are very keen to incorporate further comments, if any, for the betterment of the final manuscript.

1. Comment [A1]: As I have said in the previous comment the identified articles from each data base is needed…..PubMed=-----?, CINARI=----? For each databases

2. Comment [A2]: I haven’t seen the logical evidences to exclude case control study in this review.

3. Comment [A3]: What is your standard to say this finding is low?

Answer – According to the Ethiopian Demographic Health Survey 2019, this finding is low.

4. Comment [A4]: Have you got in your finding which showed health care equity and quality were the main determinant factors for low FP service utilization?

5. Comment [A5 & A6]: This study aimed to determine the pooled prevalence and associated factors for FP service utilization among WWDs in Ethiopia; better to state it at the end of the last paragraph of the introduction.

6. Comment [A7]: Thank you for your comment; it is accepted and corrected in the revised manuscript.

7. Comment [A8]: Which articles were included or excluded based on this reason.

Answer – Thank you for your inquiry; the included and excluded studies are cited in the revised manuscript.

8. Comment [A9]: Thank you for your comment; it is accepted and corrected in the revised manuscript.

9. Comment [A10]: Is there any logical evidence to exclude a single variable which showed significant association in the single study?

Answer– Even though there is no clear evidence to exclude a single variable that showed a significant association in the single study, meta-regression is the aggregate result of two or more studies. So to get the pooled results of different studies, the authors preferred to extract factors that were reported in two or more studies.

10. Comment [A11]: Better to state all variables even they don’t have significant association

Answer– Thank you for your comment; as we mentioned earlier in this study the variable was extracted as factors, if it is significant associations in two or more primary papers. So, in this study only three variables were extracted as a factor and among them two of them are significantly associated with the dependent variable which is seen in Table 4.

11. Comment [A13]: You have used very limited literatures for discussion.

12. Comment [A14]: Thank you for your comment; it is accepted and corrected in the revised manuscript.

Submitted filename: Second Revision Response to the Editor.docx

Decision Letter 2

20 Jul 2023

PONE-D-22-35356R2Utilization of Family Planning and Associated Factors among Women with Disabilities in Ethiopia: a systematic review and meta-analysisPLOS ONE

Please submit your revised manuscript by Sep 03 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at gro.solp@enosolp . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

- The reason to exclude case control studies not convincing.

- Excluding variables which are significant in the single study is not advisable; we can take odds ration even though it may be not significant.

Author response to Decision Letter 2

15 Aug 2023

1. The reason to exclude case control studies not convincing.

Answer: Thank you for your comment, as the authors mentioned in the manuscript on page 5 lines 2-4, both published and unpublished observational studies in English that report the prevalence and/or associated factors of family planning utilization among disabled women in Ethiopia were considered. But all studies which fulfill the inclusion criteria are crossectional, that’s why all the included studies were crossectional.

2. Excluding variables which are significant in the single study is not advisable; we can take odds ration even though it may be not significant.

Answer: Thank you for your comment, its accepted and corrected as your kind recommendation in the revised manuscript on pages 9 and 10.

Submitted filename: Response to the Editor 3.docx

Decision Letter 3

24 Aug 2023

Utilization of Family Planning and Associated Factors among Women with Disabilities in Ethiopia: a systematic review and meta-analysis

PONE-D-22-35356R3

Dear Dr.Tesfanesh,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Acceptance letter

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IMAGES

(PDF) Two decades of family planning in Ethiopia and the way forward to
Postpartum Family Planning in Ethiopia: Provider Perspectives on Male
(PDF) Factors Affecting Unmet Need for Family Planning In Southern
(PDF) Structural Determinants in Family Planning Service Utilization in
(PDF) Modern Family Planning Utilization and Its Associated Factors
(PDF) Paving the way for universal family planning coverage in Ethiopia

COMMENTS

Knowledge, attitude and practice towards family planning among
To assess the knowledge and attitude regarding family planning and the practice of family planning among the women of reproductive age group in South Achefer District, Northwest Ethiopia, 2017.The study showed that the overall proper knowledge, attitude ...
Modern Family Planning Utilization and Its Associated Factors among
Background. The use of modern family planning methods among women of reproductive age (15-49 years) is of public health importance in Ethiopia. Nationally, modern family planning method use remains a...
Women's decisions regarding family planning use and its ...
There are studies on women's decision-making in family planning use; however, there are inconsistent findings. Therefore, this review protocol aims to determine the pooled prevalence of women's decision-making regarding family planning use and its determinants in Ethiopia.
(Pdf) Knowledge, Attitude and Practice of Family Planning in East
This review is aimed to investigate family planning knowledge, attitudes, and practices in east African countries. through published papers.A re view was conducted on knowledge, attitude and ...
Family Planning Knowledge, Attitude and Practice among Married ...
Background Understanding why people do not use family planning is critical to address unmet needs and to increase contraceptive use. According to the Ethiopian Demographic and Health Survey 2011, most women and men had knowledge on some family planning methods but only about 29% of married women were using contraceptives. 20% women had an unmet need for family planning. We examined knowledge ...
Two decades of family planning in Ethiopia and the way forward to
Family planning (FP) is a human right, and ensuring women's access to FP is central to protecting the health and wellbeing of mothers and children. Over the past two decades, Ethiopia has made FP service more widely available, increasing the contraceptive prevalence rate from 8% in 2000 to 41% in 2019. This remarkable fivefold increase can be attributed to the country's overall development ...
Knowledge and Attitude Towards Family Planning Among Women of ...
Therefore, there is a need to assess the level of knowledge and attitudes towards family planning, and associated factors among reproductive-age women in the four emerging regions of Ethiopia.
Knowledge of preconception care and its association with family
Therefore, this systematic review and meta-analysis aimed to estimate the pooled knowledge level of PCC and its association with family planning usage among women in Ethiopia.
(PDF) Women's decisions regarding family planning use and its
Therefore, this review protocol aims to determine the pooled prevalence of women's decision-making regarding family planning use and its determinants in Ethiopia.
Women's decision-making power regarding family planning use and
Forest plot showing the association between knowledge women on family planning methods and women's decisions regarding family planning use in Ethiopia.
Uptake of postpartum modern family planning and its associated factors
This study aimed to estimate the pooled prevalence and factors associated with postpartum modern contraceptive use in Ethiopia.Systematic Reviews and …
Determinants of modern family planning methods in Ethiopia: A community
Abstract In 2019, Ethiopia had a total fertility rate of 4.2 births per woman with the rates varying significantly across regions. The Federal Ministry of Health of Ethiopia announced "Ethiopia FP 2020" to address the high fertility rate, aiming to reduce it to 3.0 by 2020. This study aimed to identify the determinants of the use of modern family planning services in the Amhara, Oromia ...
Prevalence and associated factors of client satisfaction with family
Therefore, this systematic review and meta-analysis was intended to estimate the pooled prevalence of client satisfaction with Ethiopian family planning services in Ethiopia. The findings of the review can be used to develop strategies and draft policies in the country.
Factors associated with long-acting family planning service utilization
Background Even though the modern contraceptive use was improved in Ethiopia, the utilization of long-acting family planning services is still low because of numerous factors. The aim of this systematic review was to synthesize logical evidence about factors associated with long acting family planning service utilization in Ethiopia.
Quality of family planning services and associated factors among
Therefore, the objective of this study was to assess quality of family planning services and associated factors among reproductive age women attending family planning unit in public health facilities in Dire Dawa, Eastern Ethiopia.
Knowledge, attitude and practice towards family planning among
Objective To assess the knowledge and attitude regarding family planning and the practice of family planning among the women of reproductive age group in South Achefer District, Northwest Ethiopia, 2017. Result The study showed that the overall proper knowledge, attitude and practice of women towards family planning (FP) was 42.3%, 58.8%, and 50.4% respectively. Factors associated with the ...
Full article: Utilization of Family Planning Methods and Associated
Utilization of Family Planning Methods and Associated Factors Among Reproductive-Age Women with Disability in Arba Minch Town, Southern Ethiopia
Mapping evidence on postpartum modern family planning service uptake
A wide knowledge and research gap on postpartum family planning service was identified through this scoping review of the scientific literature. Ethiopia is one of the geographical countries that has achieved a speedy increase in its trendy contraceptive prevalence rate increasing from 10% in 2005 to 60% in 2019 ( 20 ).
Determinants of the Use of Family Planning Methods in Ethiopia Using a
Family planning is the most effective method to control the continuing growth of the population. Ethiopia is currently one of the fastest growing countries in the world, with a growth rate of 3.02% per year. In the next forty to fifty years, Ethiopia is predicted to account for a significant portion of the population growth expected throughout Africa. According to Ethiopia Mini Demographic and ...
PDF National Guideline for Family Planning Services In Ethiopia
o improving maternal health and bringing about development. Since the revision of the first guideline in 2011, there have been various local and international updates on the provision of family planning services. The revision of the second national family planning guideline follows the development of the health sector plan, the release of revised WHO medical eligibility criteria, and the need ...
Male involvement in the use of family planning and associated factors
Male involvement in the use of family planning and associated factors in Gondar City, Northwest Ethiopia: A community-based cross-sectional study Department of Environmental and Occupational Health and Safety, Institute of Public Health, University of Gondar, Gondar City, Ethiopia
Utilization of family planning and associated factors among women with
Conclusion The finding of this study showed that utilization of family planning among women with disability is relatively lower than the Ethiopian Demographic Health Survey 2019. Therefore, the discussions with the partner and their engagement in decisions to use family planning are critical to increase its use. Go to:
58527 PDFs
Explore the latest full-text research PDFs, articles, conference papers, preprints and more on FAMILY PLANNING. Find methods information, sources, references or conduct a literature review on ...

Family Planning Knowledge, Attitude and Practice among Married Couples in Jimma Zone, Ethiopia

Materials and Methods

Data analysis

Ethical considerations

Socio Demographic Characteristics

Fertility preferences

Knowledge about Family Planning

Attitudes towards Family Planning

Contraceptive Practice

Conclusion and Recommendations

Acknowledgments

Author Contributions

Sexual and Reproductive Health in Ethiopia: Gains and Reflections Over the Past Two Decades

Two decades of family planning in Ethiopia and the way forward to sustain hard-fought gains!

Introduction

Availability of data and materials

Abbreviations

Acknowledgments

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Reproductive Health

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Knowledge and Attitude Towards Family Planning Among Women of Reproductive Age in Emerging Regions of Ethiopia

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Quality of family planning services and associated factors among reproductive age women attending family planning unit at public health facilities in Dire Dawa, Eastern Ethiopia, 2021

Introduction

Conclusion and recommendation

Study setting and design

Study population and sampling procedure

Outcome variable

Measurement

Data collection tool and procedures

Data processing and analysis

Socio-demographic characteristics of respondents

Availability and functionality of logistic supplies for family planning services

Satisfactory facility environment

Availability of minimum equipment to offer Family Planning services

Availability of Family Planning contraceptive supplies

Availability of reproductive health guidelines and FP IEC materials

Appropriate constellation of services

Provider competency for provision of family planning services

Client-provider interaction from client perspective

Client satisfaction with family planning services provided

Factors associated with client satisfaction with family planning services

Availability of data and materials

Acknowledgements

Author information

Contributions

Corresponding author

Ethics declarations

Consent for publication

Competing of interest

Additional information

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Contraception and Reproductive Medicine

Knowledge, attitude and practice towards family planning among reproductive age women in a resource limited settings of Northwest Ethiopia

Introduction

Methods and materials

Data processing and analysis

Socio-demographic characteristics of participants

Knowledge status of participants

Attitude status of participants

Practice on family planning

Factors associated with family planning practice

Conclusion and recommendation

Limitation of the study

Abbreviations